Healthcare Provider Details

I. General information

NPI: 1619097300
Provider Name (Legal Business Name): COLLEEN MARY JEWELL MA LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10299 GRAND RIVER RD STE I
BRIGHTON MI
48116-9558
US

IV. Provider business mailing address

10299 GRAND RIVER RD STE I
BRIGHTON MI
48116-9558
US

V. Phone/Fax

Practice location:
  • Phone: 810-844-7300
  • Fax:
Mailing address:
  • Phone: 810-844-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301010643
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: