Healthcare Provider Details

I. General information

NPI: 1861830697
Provider Name (Legal Business Name): JONATHAN EDWARDS LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2013
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5331 PLYMOUTH RD
ANN ARBOR MI
48105-9520
US

IV. Provider business mailing address

2915 DEAKE AVE
ANN ARBOR MI
48108-1336
US

V. Phone/Fax

Practice location:
  • Phone: 734-996-9111
  • Fax: 734-996-1950
Mailing address:
  • Phone: 734-210-0794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW004811
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801103083
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: