Healthcare Provider Details

I. General information

NPI: 1942130653
Provider Name (Legal Business Name): JUSTICE WILLIS CLINICAL INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 W FRANKLIN ST
JACKSON MI
49201-1674
US

IV. Provider business mailing address

1902 TANBARK CIR
JACKSON MI
49203-1273
US

V. Phone/Fax

Practice location:
  • Phone: 734-726-4038
  • Fax:
Mailing address:
  • Phone: 734-726-4038
  • 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: