Healthcare Provider Details

I. General information

NPI: 1255702080
Provider Name (Legal Business Name): JANESSA GABRIELLE PERRIN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANESSA BLACK

II. Dates (important events)

Enumeration Date: 10/20/2015
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N MAPLE RD
ANN ARBOR MI
48103-2827
US

IV. Provider business mailing address

6549 TOWN CENTER DR STE A
CLARKSTON MI
48346-4824
US

V. Phone/Fax

Practice location:
  • Phone: 734-669-3610
  • Fax:
Mailing address:
  • Phone: 248-620-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1901460
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801105890
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: