Healthcare Provider Details

I. General information

NPI: 1134345176
Provider Name (Legal Business Name): JACQUELINE MARIE RAXTER M.A.,L.M.S.W.,L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 BAGLEY ST SUITE 1100
DETROIT MI
48226-1400
US

IV. Provider business mailing address

25839 CUNNINGHAM AVE
WARREN MI
48091-1487
US

V. Phone/Fax

Practice location:
  • Phone: 313-961-4890
  • Fax: 313-961-1047
Mailing address:
  • Phone: 586-754-5933
  • Fax: 313-961-1047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801034425
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: