=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629831763
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA CLAWSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2024
-----------------------------------------------------
Last Update Date | 02/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1124 AUSTIN ST
-----------------------------------------------------
City | CASSOPOLIS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-228-5177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 960 M 60 E
-----------------------------------------------------
City | CASSOPOLIS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49031-9339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------