Provider Demographics
NPI:1457826364
Name:VANDYCK, JENNIFER G
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:G
Last Name:VANDYCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 S 4TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:ISHPEMING
Mailing Address - State:MI
Mailing Address - Zip Code:49849-2168
Mailing Address - Country:US
Mailing Address - Phone:906-228-9699
Mailing Address - Fax:888-977-2109
Practice Address - Street 1:97 S 4TH ST STE C
Practice Address - Street 2:
Practice Address - City:ISHPEMING
Practice Address - State:MI
Practice Address - Zip Code:49849-2168
Practice Address - Country:US
Practice Address - Phone:906-288-9696
Practice Address - Fax:888-977-2109
Is Sole Proprietor?:No
Enumeration Date:2018-10-06
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)