MEDICARE: JAELLE MACKENZIE RICHARDSON LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6801095829	MI

General Provider Information

NPI Number	:	1316768278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAELLE MACKENZIE RICHARDSON LMSW

Provider Business Mailing Address
First Line	:	28514 LINCOLNVIEW DR
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-5248
Country	:	US
Telephone Number	:	517-250-2270
Fax Number	:

Provider Business Practice Location Address
First Line	:	28514 LINCOLNVIEW DR
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-5248
Country	:	US
Telephone Number	:	517-250-2270
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2024
Last Update Date	:	10/22/2024

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Directions to “ JAELLE MACKENZIE RICHARDSON LMSW” Practice Location

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