=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295148583
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELYN GOLDEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2014
-----------------------------------------------------
Last Update Date | 11/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 707 W MILWAUKEE ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48202-2943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-989-9444
-----------------------------------------------------
Fax | 313-487-9026
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 707 W MILWAUKEE ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48202-2943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-989-9444
-----------------------------------------------------
Fax | 313-487-9026
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TM1800X
-----------------------------------------------------
Taxonomy Name | Intellectual & Developmental Disabilities Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------