Healthcare Provider Details

I. General information

NPI: 1346029568
Provider Name (Legal Business Name): JERRY DEONITA PARKER JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2023
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 W LAKE LANSING RD 200
EAST LANSING MI
48823-6372
US

IV. Provider business mailing address

830 W LAKE LANSING RD STE 200
EAST LANSING MI
48823-6372
US

V. Phone/Fax

Practice location:
  • Phone: 517-624-1416
  • Fax: 517-237-4170
Mailing address:
  • Phone: 517-624-1416
  • Fax: 517-237-4170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: