Basic Information
| Provider Information | |||||||||
| NPI: | 1730562422 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDENBERG | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | CHRISTIAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1331 MOURSUND AVENUE | ||||||||
| Address2: | BLDG. G RM 115-118 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770305389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137995033 | ||||||||
| FaxNumber: | 7137975982 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 WEALTHY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495035247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168408805 | ||||||||
| FaxNumber: | 6168409642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2015 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 5101025744 | MI | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 125.066293 | IL | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.