Healthcare Provider Details

I. General information

NPI: 1497867014
Provider Name (Legal Business Name): JACOB I MEGDELL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2422 JOLLY RD SUITE 300
OKEMOS MI
48864-3514
US

IV. Provider business mailing address

PO BOX 10
MASON MI
48854-0010
US

V. Phone/Fax

Practice location:
  • Phone: 517-347-6944
  • Fax: 517-347-6912
Mailing address:
  • Phone: 517-676-9788
  • Fax: 517-676-3438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301007262
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: