=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558718502
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELINE MARIA BEAVERS LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2016
-----------------------------------------------------
Last Update Date | 11/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 89 E EDSEL FORD FWY STE 200
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48202-3742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-339-2660
-----------------------------------------------------
Fax | 734-207-5326
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19300 APPOLINE ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48235-1215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-339-2660
-----------------------------------------------------
Fax | 734-207-5326
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801109721
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------