Healthcare Provider Details

I. General information

NPI: 1922828367
Provider Name (Legal Business Name): JESSICA LEE CARPENTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2024
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13980 SCHAVEY RD
DEWITT MI
48820-9013
US

IV. Provider business mailing address

2460 N EIFERT RD
HOLT MI
48842-1030
US

V. Phone/Fax

Practice location:
  • Phone: 517-899-2820
  • Fax:
Mailing address:
  • Phone: 517-899-2820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: