Provider Demographics
NPI:1720571045
Name:JANNESS, LAUREN (OTR/L)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:JANNESS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 LEONARD ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5515
Mailing Address - Country:US
Mailing Address - Phone:248-224-8871
Mailing Address - Fax:
Practice Address - Street 1:1450 LEONARD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5515
Practice Address - Country:US
Practice Address - Phone:616-774-8789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.012097225X00000X
MI5201010451225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056.012097OtherSTATE LICENSE
390494OtherNATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY CERTIFICATION
MI5201010451OtherSTATE LICENSE