Healthcare Provider Details

I. General information

NPI: 1003469842
Provider Name (Legal Business Name): MONICA JEWELL EAGLE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4925 PACKARD ST
ANN ARBOR MI
48108-1521
US

IV. Provider business mailing address

1000 VICTORS WAY
ANN ARBOR MI
48108-2744
US

V. Phone/Fax

Practice location:
  • Phone: 734-971-9781
  • Fax:
Mailing address:
  • Phone: 734-973-6779
  • Fax: 734-973-6609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801113999
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: