Provider Demographics
NPI:1194971523
Name:GOVERNAL, JAMIE BAUM (AUD)
Entity type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:BAUM
Last Name:GOVERNAL
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:MARIAN
Other - Last Name:BAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-391-2862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601001057231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2008017341OtherLICENSE
MO2008017341Medicaid
MO2008017341OtherLICENSE