Basic Information
| Provider Information | |||||||||
| NPI: | 1508103060 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEMPKE | ||||||||
| FirstName: | JESSICA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 GROVE ST | ||||||||
| Address2: | IRONMEN HEALTH CENTER | ||||||||
| City: | MANCELONA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496598018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315879840 | ||||||||
| FaxNumber: | 2315879846 | ||||||||
| Practice Location | |||||||||
| Address1: | NELSON ELEMENTARY | ||||||||
| Address2: | 550 W GRAND AVENUE | ||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494412336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317336680 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2013 | ||||||||
| LastUpdateDate: | 09/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401012439 | MI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 1508103060 | 05 | MI | MEDICAID |