Healthcare Provider Details

I. General information

NPI: 1275466351
Provider Name (Legal Business Name): DETROIT JIT SHUT SHOWS DOWN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 TENNESSEE ST
DETROIT MI
48215-3052
US

IV. Provider business mailing address

441 TENNESSEE ST
DETROIT MI
48215-3052
US

V. Phone/Fax

Practice location:
  • Phone: 313-210-2684
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. LAMAR BRYANT
Title or Position: PRESIDENT
Credential:
Phone: 313-210-2684