Provider Demographics
NPI:1407633589
Name:SAWYER-MOORE, JONELL T
Entity type:Individual
Prefix:
First Name:JONELL
Middle Name:T
Last Name:SAWYER-MOORE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 WATKINS ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-1471
Mailing Address - Country:US
Mailing Address - Phone:616-315-7101
Mailing Address - Fax:
Practice Address - Street 1:1126 WATKINS ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-1471
Practice Address - Country:US
Practice Address - Phone:616-315-7101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225700000X, 374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist