Provider Demographics
NPI:1194088377
Name:KJC323PLLC
Entity type:Organization
Organization Name:KJC323PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:JANDERNOA
Authorized Official - Last Name:CRAMER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD,LP
Authorized Official - Phone:616-464-3424
Mailing Address - Street 1:967 SPAULDING AVE SE
Mailing Address - Street 2:SUITE E
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-3700
Mailing Address - Country:US
Mailing Address - Phone:616-464-4324
Mailing Address - Fax:616-949-5336
Practice Address - Street 1:967 SPAULDING AVE SE
Practice Address - Street 2:SUITE E
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-3700
Practice Address - Country:US
Practice Address - Phone:616-464-4324
Practice Address - Fax:616-949-5336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-21
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013342103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty