Healthcare Provider Details

I. General information

NPI: 1285219964
Provider Name (Legal Business Name): JULIA PUCKETT PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JAE PUCKETT PH.D.

II. Dates (important events)

Enumeration Date: 03/14/2021
Last Update Date: 10/14/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2929 COVINGTON CT
LANSING MI
48912-4941
US

IV. Provider business mailing address

812 E JOLLY RD
LANSING MI
48910-6818
US

V. Phone/Fax

Practice location:
  • Phone: 517-798-6745
  • Fax:
Mailing address:
  • Phone: 517-346-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301017827
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: