MEDICARE: HALO CHRISTIAN COUNSELING CENTER LLC

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
2	101YM0800X	Mental Health Counselor		MI

General Provider Information

NPI Number	:	1083130603
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HALO CHRISTIAN COUNSELING CENTER LLC

Provider Business Mailing Address
First Line	:	26105 ORCHARD LAKE RD STE 309
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-4510
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	26105 ORCHARD LAKE RD STE 309
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-4510
Country	:	US
Telephone Number	:	313-414-8119
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JAMELL JEFFESON
Credential	:	MA, LPC
Telephone Number	:	313-414-8119

Provider Enumeration Date	:	08/15/2017
Last Update Date	:	08/15/2017

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