Healthcare Provider Details

I. General information

NPI: 1194395707
Provider Name (Legal Business Name): LIGHTHOUSE OF JACKSON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2021
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 E MAIN ST
SPRING ARBOR MI
49283-9673
US

IV. Provider business mailing address

2548 S SANDSTONE RD
JACKSON MI
49201-9374
US

V. Phone/Fax

Practice location:
  • Phone: 517-240-9329
  • Fax:
Mailing address:
  • Phone: 517-240-9329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KEN FLOWERS
Title or Position: MEMBER, CFO
Credential:
Phone: 517-240-9329