MEDICARE: JESSICA MARIE SHORT-SLACK LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6801098796	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023489770
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA MARIE SHORT-SLACK LMSW

Provider Business Mailing Address
First Line	:	PO BOX 672
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48480-0672
Country	:	US
Telephone Number	:	810-429-7359
Fax Number	:

Provider Business Practice Location Address
First Line	:	5122 PASADENA AVE
Second Line	:
City	:	FLUSHING
State	:	MI
Zip	:	48433-2417
Country	:	US
Telephone Number	:	810-429-7359
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/07/2015
Last Update Date	:	12/12/2022

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