=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144954033
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELINE ANN PRESKIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2022
-----------------------------------------------------
Last Update Date | 07/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7375 WOODWARD AVE STE 2800
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48202-3157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-710-8744
-----------------------------------------------------
Fax | 855-568-2494
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2281 ALLARD AVE
-----------------------------------------------------
City | GROSSE POINTE WOODS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48236-1913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-808-7038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------