Basic Information
| Provider Information | |||||||||
| NPI: | 1346719515 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IPEMA | ||||||||
| FirstName: | JORDAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2581 N LAKESHORE DR | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693770092 | ||||||||
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| Practice Location | |||||||||
| Address1: | 888 TERRACE ST | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316724663 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2018 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 08805 | MD | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 0119008332 | VA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 120461 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 5201009449 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.