Provider Demographics
NPI:1063182426
Name:COLLVER, JEROD TIMOTHY
Entity type:Individual
Prefix:
First Name:JEROD
Middle Name:TIMOTHY
Last Name:COLLVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 E BELTLINE AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1490 E BELTLINE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4336
Practice Address - Country:US
Practice Address - Phone:616-443-7557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant