Healthcare Provider Details

I. General information

NPI: 1629141007
Provider Name (Legal Business Name): MITCHELL SCOTT WEISBROD PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

437 FERN AVE STE C
JACKSON MI
49202-3970
US

IV. Provider business mailing address

115 S WEST AVE STE 1
JACKSON MI
49201-2085
US

V. Phone/Fax

Practice location:
  • Phone: 989-292-3592
  • Fax: 517-780-9239
Mailing address:
  • Phone: 517-544-7700
  • Fax: 517-612-8817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301008984
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: