Healthcare Provider Details

I. General information

NPI: 1790319101
Provider Name (Legal Business Name): JACKSON MOREHEAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W MAIN ST STE 207
NORTHVILLE MI
48167-1584
US

IV. Provider business mailing address

5425 S KING ST
LITTLETON CO
80123-2910
US

V. Phone/Fax

Practice location:
  • Phone: 734-738-0897
  • Fax:
Mailing address:
  • Phone: 970-988-4558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301018373
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401222657
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: