Healthcare Provider Details

I. General information

NPI: 1104231729
Provider Name (Legal Business Name): JACQUELYN BUFFO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15420 19 MILE RD
CLINTON TOWNSHIP MI
48038-6339
US

IV. Provider business mailing address

3079 S BALDWIN RD # 3020
LAKE ORION MI
48359-1028
US

V. Phone/Fax

Practice location:
  • Phone: 586-226-7007
  • Fax:
Mailing address:
  • Phone: 586-464-7432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6401013525
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401013525
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: