Provider Demographics
NPI:1609514306
Name:MARENTETTE, JORDAN L (OD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:L
Last Name:MARENTETTE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E PARIS AVENUE SE
Mailing Address - Street 2:STE 130
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3680
Mailing Address - Country:US
Mailing Address - Phone:616-949-2001
Mailing Address - Fax:616-949-8620
Practice Address - Street 1:1000 E PARIS AVENUE SE
Practice Address - Street 2:STE 130
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3680
Practice Address - Country:US
Practice Address - Phone:616-949-2001
Practice Address - Fax:616-949-8620
Is Sole Proprietor?:No
Enumeration Date:2022-05-23
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005772152W00000X
OHOPT.007036152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist