Healthcare Provider Details

I. General information

NPI: 1922309541
Provider Name (Legal Business Name): JESSICA GUPTA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2010
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 WALNUT BLVD SUITE 2
ROCHESTER MI
48307-2086
US

IV. Provider business mailing address

115 WALNUT BLVD SUITE 2
ROCHESTER MI
48307-2086
US

V. Phone/Fax

Practice location:
  • Phone: 248-766-0818
  • Fax: 248-650-3225
Mailing address:
  • Phone: 248-766-0818
  • Fax: 248-650-3225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1000350
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801093267
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: