Healthcare Provider Details

I. General information

NPI: 1548649502
Provider Name (Legal Business Name): JESSICA BAKER MLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2015
Last Update Date: 04/07/2024
Certification Date: 04/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N CENTER ST
NORTHVILLE MI
48167-1277
US

IV. Provider business mailing address

315 N CENTER ST
NORTHVILLE MI
48167-1277
US

V. Phone/Fax

Practice location:
  • Phone: 313-656-4052
  • Fax: 313-656-4053
Mailing address:
  • Phone: 313-656-4052
  • Fax: 313-656-4053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301016857
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: