Healthcare Provider Details

I. General information

NPI: 1144769894
Provider Name (Legal Business Name): JESSICA MCMAHON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 WOODRUFF AVE APT 4
LANSING MI
48912-4919
US

IV. Provider business mailing address

2920 WOODRUFF AVENUE APARTMENT 4
LANSING MI
48912
US

V. Phone/Fax

Practice location:
  • Phone: 517-449-7357
  • Fax:
Mailing address:
  • Phone: 517-449-7357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801096092
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: