Provider Demographics
NPI:1013296144
Name:TUBERGEN, JESSICA CATHERINE (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CATHERINE
Last Name:TUBERGEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:DEKKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:44 E 8TH ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3575
Mailing Address - Country:US
Mailing Address - Phone:616-392-3197
Mailing Address - Fax:
Practice Address - Street 1:3491 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MI
Practice Address - Zip Code:49419-9512
Practice Address - Country:US
Practice Address - Phone:269-751-2150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-07
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003228225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant