=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427769215
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAYCAR WELLNESS GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2022
-----------------------------------------------------
Last Update Date | 12/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 47 CARRIAGE WAY
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197-7430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-757-0308
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47 CARRIAGE WAY
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197-7430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-757-0308
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEARALD DUDLEY II
-----------------------------------------------------
Credential | LMSW, LISW
-----------------------------------------------------
Telephone | 734-757-0308
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------