Provider Demographics
NPI:1366891319
Name:VANDER WAL, JORDIE (LMSW, CAADC)
Entity type:Individual
Prefix:
First Name:JORDIE
Middle Name:
Last Name:VANDER WAL
Suffix:
Gender:M
Credentials:LMSW, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 HOOVER BLVD STE 10
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3755
Mailing Address - Country:US
Mailing Address - Phone:616-591-9000
Mailing Address - Fax:
Practice Address - Street 1:238 HOOVER BLVD STE 10
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3755
Practice Address - Country:US
Practice Address - Phone:616-591-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011092781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical