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General NPI Number Information
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NPI Number | 1821588294
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Entity Type | Individual
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Provider Name | JIMMY IVY
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Gender | Male
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Dates
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Enumeration Date | 05/11/2018
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Last Update Date | 08/03/2022
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Provider Practice Location Address
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Address Line | 7310 WOODWARD AVE
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City | DETROIT
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State | MI
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Zip | 48202-3165
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Country | US
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Telephone | 313-230-8504
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Fax |
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Provider Business Mailing Address
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Address Line | 25610 W 12 MILE RD
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City | SOUTHFIELD
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State | MI
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Zip | 48034-8030
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Country | US
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Telephone | 517-962-6256
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Fax |
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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 | 6801102170
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 6801113515
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License Number State | MI
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