Healthcare Provider Details

I. General information

NPI: 1306380845
Provider Name (Legal Business Name): MS. JACQUELINE NICOLE FETTES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2016
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 STODDARD RD
RICHMOND MI
48062-2505
US

IV. Provider business mailing address

134 ELIZABETH ST
CROSWELL MI
48422-1112
US

V. Phone/Fax

Practice location:
  • Phone: 810-392-2167
  • Fax: 810-392-2057
Mailing address:
  • Phone: 810-712-9030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: