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General NPI Number Information
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NPI Number | 1699635284
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Entity Type | Individual
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Provider Name | JACOB MAXWELL LLMSW
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Gender | Male
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Dates
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Enumeration Date | 11/15/2025
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Last Update Date | 11/15/2025
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Provider Practice Location Address
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Address Line | 11662 MARTIN RD
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City | WARREN
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State | MI
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Zip | 48093-4588
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Country | US
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Telephone | 586-558-6868
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Fax | 586-558-6893
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Provider Business Mailing Address
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Address Line | 8717 CADILLAC AVE
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City | WARREN
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State | MI
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Zip | 48089-2479
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Country | US
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Telephone | 810-858-7018
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Fax | 586-558-6893
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6851120861
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License Number State | MI
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