Provider Demographics
NPI:1770623399
Name:DYER, JANE RANDALL (LMSW)
Entity type:Individual
Prefix:MRS
First Name:JANE
Middle Name:RANDALL
Last Name:DYER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MS
Other - First Name:JANE
Other - Middle Name:RANDALL
Other - Last Name:CRISSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:3949 SPARKS DR SE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6110
Mailing Address - Country:US
Mailing Address - Phone:616-957-5850
Mailing Address - Fax:616-957-5853
Practice Address - Street 1:3949 SPARKS DR SE
Practice Address - Street 2:SUITE 103
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6110
Practice Address - Country:US
Practice Address - Phone:616-957-5850
Practice Address - Fax:616-957-5853
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010720351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP26430002Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NUMBE