Provider Demographics
NPI:1306489240
Name:DEPOY, JAY
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:DEPOY
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 1:231 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3126
Mailing Address - Country:US
Mailing Address - Phone:616-396-5284
Mailing Address - Fax:
Practice Address - Street 1:231 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3126
Practice Address - Country:US
Practice Address - Phone:616-396-6872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 175T00000X, 171M00000X
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No175T00000XOther Service ProvidersPeer Specialist