Healthcare Provider Details

I. General information

NPI: 1730466632
Provider Name (Legal Business Name): JACQUELYN JUANITA TOBEY LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2011
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 CHURCH ST RM 313
PLYMOUTH MI
48170-1689
US

IV. Provider business mailing address

50256 JACKSON LN
CANTON MI
48188-3436
US

V. Phone/Fax

Practice location:
  • Phone: 734-215-7202
  • Fax: 856-997-1717
Mailing address:
  • Phone: 734-968-6480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301012834
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: