Healthcare Provider Details

I. General information

NPI: 1700912565
Provider Name (Legal Business Name): PRISCILLA GOLDINE FLEMING LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

726 UNION ST
JACKSON MI
49203-3072
US

IV. Provider business mailing address

726 UNION ST
JACKSON MI
49203-3072
US

V. Phone/Fax

Practice location:
  • Phone: 906-284-2512
  • Fax:
Mailing address:
  • Phone: 906-284-2512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301010021
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: