Provider Demographics
NPI:1649574021
Name:JACK, GERALDINE MARIE (BS, ETS)
Entity Type:Individual
Prefix:
First Name:GERALDINE
Middle Name:MARIE
Last Name:JACK
Suffix:
Gender:F
Credentials:BS, ETS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 E BELTLINE AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4336
Mailing Address - Country:US
Mailing Address - Phone:616-450-6482
Mailing Address - Fax:
Practice Address - Street 1:1490 E BELTLINE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4336
Practice Address - Country:US
Practice Address - Phone:616-450-6482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-29
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
MI000000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist