Provider Demographics
NPI:1710457858
Name:SIKKEMA, JASON DOUGLAS (MA LLP)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DOUGLAS
Last Name:SIKKEMA
Suffix:
Gender:M
Credentials:MA LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1826 RIDGEMOOR DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-5145
Mailing Address - Country:US
Mailing Address - Phone:616-322-4575
Mailing Address - Fax:
Practice Address - Street 1:1055 MEDICAL PARK DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3607
Practice Address - Country:US
Practice Address - Phone:616-940-0253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-02
Last Update Date:2018-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017068103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling