Healthcare Provider Details

I. General information

NPI: 1083170963
Provider Name (Legal Business Name): JESSICA AMBER BAZAN DERAEDT LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2019
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 HOMEWILD AVE
JACKSON MI
49201-1835
US

IV. Provider business mailing address

1108 HOMEWILD AVE
JACKSON MI
49201-1835
US

V. Phone/Fax

Practice location:
  • Phone: 231-679-0648
  • Fax:
Mailing address:
  • Phone: 231-679-0648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801101750
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: