Healthcare Provider Details

I. General information

NPI: 1386010205
Provider Name (Legal Business Name): JESLYN ELIZABETH AGEE LLBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2015
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 COBB ST
CADILLAC MI
49601-2540
US

IV. Provider business mailing address

1223 BARLOW ST
TRAVERSE CITY MI
49686-4256
US

V. Phone/Fax

Practice location:
  • Phone: 231-775-3463
  • Fax: 231-775-1692
Mailing address:
  • Phone: 517-612-4045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802088105
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: