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General NPI Number Information
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NPI Number | 1255856142
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Entity Type | Individual
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Provider Name | JESSICA JUNE DRAKE
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Gender | Female
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Dates
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Enumeration Date | 08/11/2017
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Last Update Date | 04/21/2023
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Provider Practice Location Address
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Address Line | 595 FOREST AVE
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City | PLYMOUTH
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State | MI
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Zip | 48170-1775
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Country | US
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Telephone | 605-759-4385
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Fax |
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Provider Business Mailing Address
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Address Line | 9004 ROCKLAND
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City | REDFORD
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State | MI
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Zip | 48239-1888
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Country | US
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Telephone | 605-759-4385
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TB0200X
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Taxonomy Name | Cognitive & Behavioral Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 6361007695
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License Number State | MI
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