Healthcare Provider Details

I. General information

NPI: 1306009196
Provider Name (Legal Business Name): JACK D WOODBURN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MILITARY ST
PORT HURON MI
48060-5418
US

IV. Provider business mailing address

1101 MILITARY ST
PORT HURON MI
48060-5418
US

V. Phone/Fax

Practice location:
  • Phone: 810-984-5575
  • Fax: 810-984-6433
Mailing address:
  • Phone: 810-984-5575
  • Fax: 810-984-6433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401000326
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: