Provider Demographics
NPI:1336340140
Name:VANLEEUWEN, JERRY BERNARD (PHD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:BERNARD
Last Name:VANLEEUWEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:B
Other - Last Name:VANLEEUWEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, PC
Mailing Address - Street 1:6255 28TH ST SE STE M
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6966
Mailing Address - Country:US
Mailing Address - Phone:616-458-5294
Mailing Address - Fax:616-458-5295
Practice Address - Street 1:6255 28TH ST SE STE M
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6966
Practice Address - Country:US
Practice Address - Phone:616-458-5294
Practice Address - Fax:616-458-5295
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC1900X
MI4101000398103TF0000X
MI6301003978103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM54200Medicare ID - Type Unspecified