Provider Demographics
NPI:1437223401
Name:WAN, JESSACA J (LMSW)
Entity Type:Individual
Prefix:MS
First Name:JESSACA
Middle Name:J
Last Name:WAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:JESSACA
Other - Middle Name:J
Other - Last Name:KOOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-455-5000
Mailing Address - Fax:
Practice Address - Street 1:2118 3 MILE RD NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-1425
Practice Address - Country:US
Practice Address - Phone:616-364-1500
Practice Address - Fax:616-364-6400
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801086286104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
38 2831313OtherTOUCHSTONE ID #
38 2831313OtherTOUCHSTONE ID #