Healthcare Provider Details

I. General information

NPI: 1538599485
Provider Name (Legal Business Name): MR. JONATHAN DUCHARME
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2013
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N 4TH AVE
ANN ARBOR MI
48104-5503
US

IV. Provider business mailing address

555 TOWNER / PO BOX 915
YPSILANTI MI
48198
US

V. Phone/Fax

Practice location:
  • Phone: 734-222-3750
  • Fax: 734-222-3731
Mailing address:
  • Phone: 734-544-3000
  • Fax: 734-544-6732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801095226
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: