MEDICARE: EVERLASTING HOPE PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	104100000X	Social Worker
3	251B00000X	Case Management Agency
4	251S00000X	Community/Behavioral Health Agency
5	252Y00000X	Early Intervention Provider Agency
6	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1871029546
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERLASTING HOPE PLLC

Provider Business Mailing Address
First Line	:	2901 S ETHEL ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48217-1531
Country	:	US
Telephone Number	:	313-775-6335
Fax Number	:

Provider Business Practice Location Address
First Line	:	2901 S ETHEL ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48217-1531
Country	:	US
Telephone Number	:	313-775-6335
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL THERAPIST
Name	:	CHERYL ANN JACKSON
Credential	:	LMSW, MSW, MBA
Telephone Number	:	313-775-6335

Provider Enumeration Date	:	05/02/2017
Last Update Date	:	05/02/2017

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Directions to “EVERLASTING HOPE PLLC ” Practice Location

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