Provider Demographics
NPI:1588216048
Name:JACK, KATHERINE (LPC)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:JACK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2042 INNWOOD DR SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5066
Mailing Address - Country:US
Mailing Address - Phone:616-260-4597
Mailing Address - Fax:
Practice Address - Street 1:3351 CLAYSTONE ST SE STE G32
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5794
Practice Address - Country:US
Practice Address - Phone:616-259-6827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0019661101YP2500X
MI6401222851101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional