Healthcare Provider Details

I. General information

NPI: 1891237186
Provider Name (Legal Business Name): JERRY COPELAND MSW, LLMSW, CAADC,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2016
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14799 DIX TOLEDO RD
SOUTHGATE MI
48195-2507
US

IV. Provider business mailing address

14799 DIX TOLEDO RD
SOUTHGATE MI
48195-2507
US

V. Phone/Fax

Practice location:
  • Phone: 734-324-8326
  • Fax: 734-324-8327
Mailing address:
  • Phone: 734-324-8326
  • Fax: 313-962-6395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851108144
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: