Individual provider Active NPI

Jessica Lynn Vandentoorn, LMSW

  • Clinical Social Worker
  • Grand Rapids, MI
National Provider Identifier
1861987216
Registry record updated Jun 20, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Social WorkerTaxonomy code 1041C0700X
License
6801098174 Issued in MI
Practice address
300 68TH St SE
Grand Rapids, MI 49548-6927
Phone
(616) 258-7467
NPI assigned
Jun 28, 2018
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 20, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Social Worker 1041C0700X 6801098174 MI Primary

Addresses

Primary practice location

300 68TH St SE
Grand Rapids, MI 49548-6927

Mailing address

300 68TH St SE
Grand Rapids, MI 49548-6927

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI
Eligible to order & refer
  • Part B services: Yes
  • Medical equipment: Yes
  • Home health: No
  • Power mobility devices: No
  • Hospice: No
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20180717001583 MI Practitioner - Clinical Social Worker 9335496751 Reassigns benefits to 1 organization

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

State licenses

LicenseStateTypeSpecialty
6801098174MIMDClinical Social Worker

Practice roles

OrganizationSpecialtyStatusNew patients
Pine Rest Christian Mental Health Services CurrentSince Mar 7, 2019 Accepting new patients
Pine Rest Christian Mental Health Services Social Worker CurrentSince Mar 7, 2019 Accepting new patients

Locations

300 68th St SE
Wyoming, MI 49548
Phone (616) 455-5000

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1530144000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1687219200000",
    "number": "1861987216",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "300 68TH ST SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495486927"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "300 68TH ST SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495486927",
            "telephone_number": "616-258-7467"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "VANDENTOORN",
        "first_name": "JESSICA",
        "middle_name": "LYNN",
        "credential": "LMSW",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2018-06-28",
        "last_updated": "2023-06-20",
        "certification_date": "2023-06-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MI",
            "license": "6801098174",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Grand Rapids, MI

Sources for this page

Verify at the official NPI Registry.