Healthcare Provider Details

I. General information

NPI: 1285605360
Provider Name (Legal Business Name): JEAN MATHER MSW, CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 BAYONNE AVE
HASLETT MI
48840-9536
US

IV. Provider business mailing address

5700 BAYONNE AVE
HASLETT MI
48840-9536
US

V. Phone/Fax

Practice location:
  • Phone: 517-339-5205
  • Fax:
Mailing address:
  • Phone: 517-339-5205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6801034276
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: