Healthcare Provider Details

I. General information

NPI: 1962925800
Provider Name (Legal Business Name): JESSICA MISIOLEK LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2017
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date: 09/19/2024
Reactivation Date: 10/17/2024

III. Provider practice location address

26300 OUTER DR
LINCOLN PARK MI
48146-2019
US

IV. Provider business mailing address

14115 DENNE ST
LIVONIA MI
48154-4305
US

V. Phone/Fax

Practice location:
  • Phone: 313-388-0472
  • Fax: 248-969-9478
Mailing address:
  • Phone: 586-909-6033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851105865
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: