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General NPI Number Information
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NPI Number | 1467221218
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Entity Type | Organization
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Legal Business Name | THE OPEN ROAD COLLECTIVE LLC
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Dates
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Enumeration Date | 12/21/2023
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Last Update Date | 12/21/2023
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Provider Practice Location Address
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Address Line | 717 W ELLSWORTH RD
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City | ANN ARBOR
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State | MI
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Zip | 48108-3343
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Country | US
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Telephone | 734-678-3097
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Fax |
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Provider Business Mailing Address
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Address Line | 1270 WARNER ST
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City | YPSILANTI
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State | MI
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Zip | 48197-4658
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CORRYN HELEN JACKSON
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Credential | LPC
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Telephone | 734-678-3097
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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