Healthcare Provider Details

I. General information

NPI: 1427621598
Provider Name (Legal Business Name): JAY MICHAEL MADDOCK MA, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5340 HOLIDAY TER STE 13
KALAMAZOO MI
49009-2181
US

IV. Provider business mailing address

5340 HOLIDAY TER STE 13
KALAMAZOO MI
49009-2181
US

V. Phone/Fax

Practice location:
  • Phone: 269-372-4140
  • Fax:
Mailing address:
  • Phone: 269-372-4140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401223782
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: