Provider Demographics
NPI:1477783843
Name:WIERENGA, JENNA SUZANN (PSYD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:SUZANN
Last Name:WIERENGA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3924 SUPERIOR ST SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1641
Mailing Address - Country:US
Mailing Address - Phone:616-403-2407
Mailing Address - Fax:
Practice Address - Street 1:4301 CANAL AVE SW
Practice Address - Street 2:STE M
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2667
Practice Address - Country:US
Practice Address - Phone:616-403-2407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-20
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015873103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical