Provider Demographics
NPI:1427325190
Name:VANDER WAAL, JEANNE MONIQUE (COTAL)
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:MONIQUE
Last Name:VANDER WAAL
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 FREDERICK AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-4042
Mailing Address - Country:US
Mailing Address - Phone:616-309-3551
Mailing Address - Fax:
Practice Address - Street 1:2100 E PROVINCIAL HOUSE DR
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-4884
Practice Address - Country:US
Practice Address - Phone:517-272-4029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-24
Last Update Date:2011-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202007161224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant