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General NPI Number Information
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NPI Number | 1003419136
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Entity Type | Organization
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Legal Business Name | HEAL THYSELF THERAPEUTICS, LLC
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Dates
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Enumeration Date | 11/20/2020
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Last Update Date | 12/01/2020
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Provider Practice Location Address
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Address Line | 1100 CORPORATE OFFICE DR STE 320
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City | MILFORD
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State | MI
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Zip | 48381-5002
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Country | US
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Telephone | 810-434-7933
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Fax |
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Provider Business Mailing Address
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Address Line | 34326 SHERIDAN ST
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City | WESTLAND
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State | MI
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Zip | 48185-8511
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Country | US
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Telephone | 810-434-7933
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | MR. DERRICK JEROME JACKSON II
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Credential | LMSW
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Telephone | 810-434-7933
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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