Provider Demographics
NPI:1912354754
Name:SUNDHOLM, JESSICA
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:SUNDHOLM
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:FELKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1330 E. GRAND RIVER AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875
Mailing Address - Country:US
Mailing Address - Phone:517-647-4327
Mailing Address - Fax:517-647-2442
Practice Address - Street 1:301 WILLIAMSTON CENTER RD.
Practice Address - Street 2:SUITE 800
Practice Address - City:WILLIAMSTON
Practice Address - State:MI
Practice Address - Zip Code:48895
Practice Address - Country:US
Practice Address - Phone:517-655-2327
Practice Address - Fax:517-655-2442
Is Sole Proprietor?:No
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101001121235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist