Healthcare Provider Details

I. General information

NPI: 1992221345
Provider Name (Legal Business Name): JENNIFER DEJA MSW PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2017
Last Update Date: 07/21/2022
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 W WOOD ST
NEWAYGO MI
49337-8991
US

IV. Provider business mailing address

PO BOX 10
MASON MI
48854-0010
US

V. Phone/Fax

Practice location:
  • Phone: 231-206-6159
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARY BETH HOUPT
Title or Position: CREDENTIALING
Credential:
Phone: 517-676-9788