Provider Demographics
NPI:1063531671
Name:BISSONETTE, JENNIFER (MSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BISSONETTE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-2629
Mailing Address - Country:US
Mailing Address - Phone:616-928-0034
Mailing Address - Fax:616-928-0036
Practice Address - Street 1:44 E 8TH ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3575
Practice Address - Country:US
Practice Address - Phone:616-928-0034
Practice Address - Fax:616-928-0036
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010797261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N96070Medicare ID - Type Unspecified