Healthcare Provider Details

I. General information

NPI: 1639550775
Provider Name (Legal Business Name): JON WEBER MASTER SOCIAL WORK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 06/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6418 DEANS HILL RD
BERRIEN CENTER MI
49102-9750
US

IV. Provider business mailing address

6728 M 140 HWY
COVERT MI
49043-9400
US

V. Phone/Fax

Practice location:
  • Phone: 269-815-5500
  • Fax:
Mailing address:
  • Phone: 269-621-5527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: