Provider Demographics
NPI:1982193256
Name:NIENHUIS, JACOB B (PHD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:B
Last Name:NIENHUIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 W WARNER ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-4709
Mailing Address - Country:US
Mailing Address - Phone:616-856-0294
Mailing Address - Fax:
Practice Address - Street 1:4488 JACKSON RD STE 7B
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103
Practice Address - Country:US
Practice Address - Phone:616-856-0294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-02
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016354103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty