Healthcare Provider Details

I. General information

NPI: 1700796463
Provider Name (Legal Business Name): JACOB WILLIAM PRUITT MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E LAKEVILLE RD
OXFORD MI
48371-5253
US

IV. Provider business mailing address

6242 WALKER DR
TROY MI
48085-1347
US

V. Phone/Fax

Practice location:
  • Phone: 248-969-5169
  • Fax:
Mailing address:
  • Phone: 248-909-0593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number6851122527
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: