Healthcare Provider Details

I. General information

NPI: 1093626954
Provider Name (Legal Business Name): CHANGE THE WORLD FOR YOU II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31923 HARLO DR APT H
MADISON HEIGHTS MI
48071-4603
US

IV. Provider business mailing address

31923 HARLO DR APT H
MADISON HEIGHTS MI
48071-4603
US

V. Phone/Fax

Practice location:
  • Phone: 586-536-1914
  • Fax:
Mailing address:
  • Phone: 586-536-1914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY A JACKSON
Title or Position: FOUNDER
Credential:
Phone: 586-536-1914