Healthcare Provider Details

I. General information

NPI: 1033946736
Provider Name (Legal Business Name): JAY MICHAELA VANDYKE
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 N CANTON CENTER RD STE 200A
CANTON MI
48187-5038
US

IV. Provider business mailing address

9409 N HAGGERTY RD
PLYMOUTH MI
48170-4696
US

V. Phone/Fax

Practice location:
  • Phone: 734-559-3540
  • Fax:
Mailing address:
  • Phone: 734-559-3540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851120010
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: