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NPI Code Detail

MEDICARE: JACQUELYN MARIE PROVENZOLA LMSW

MEDICARE: JACQUELYN MARIE PROVENZOLA 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
11041C0700XClinical Social Worker6801105007
2104100000XSocial Worker

General Provider Information

NPI Number : 1477114957
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACQUELYN MARIE PROVENZOLA LMSW
Provider Business Mailing Address
First Line : 4902 CHILSON RD
Second Line :
City : HOWELL
State : MI
Zip : 48843-9453
Country : US
Telephone Number : 248-385-2524
Fax Number : 844-640-0684
Provider Business Practice Location Address
First Line : 4902 CHILSON RD
Second Line :
City : HOWELL
State : MI
Zip : 48843-9453
Country : US
Telephone Number : 248-385-2524
Fax Number : 844-640-0684
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/25/2019
Last Update Date : 04/18/2023

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Directions to “ JACQUELYN MARIE PROVENZOLA LMSW” Practice Location

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