Provider Demographics
NPI:1609957760
Name:HULST JEPSEN PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:HULST JEPSEN PHYSICAL THERAPY INC
Other - Org Name:HULST JEPSEN PHYSICAL THERAPY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HULST
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:616-281-1144
Mailing Address - Street 1:2120 43RD ST SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-3772
Mailing Address - Country:US
Mailing Address - Phone:616-281-1144
Mailing Address - Fax:616-281-1221
Practice Address - Street 1:2120 43RD ST SE
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-3772
Practice Address - Country:US
Practice Address - Phone:616-281-1144
Practice Address - Fax:616-281-1221
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HULST JEPSEN PHYSICAL THERAPY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-17
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MI225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N41100Medicare UPIN