Provider Demographics
NPI:1780455238
Name:HULTEEN, JAMIE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:HULTEEN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 CARLTON AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-3850
Mailing Address - Country:US
Mailing Address - Phone:517-899-9856
Mailing Address - Fax:
Practice Address - Street 1:117 COURTLAND ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1031
Practice Address - Country:US
Practice Address - Phone:616-951-1077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101008311235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist