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NPI Code Detail

MEDICARE: MR. JESSE BACON MSW

MEDICARE: MR. JESSE BACON MSW
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 Worker
2104100000XSocial Worker6801095708MI

General Provider Information

NPI Number : 1548605173
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JESSE BACON MSW
Provider Business Mailing Address
First Line : 18303 E 10 MILE RD STE 200
Second Line :
City : ROSEVILLE
State : MI
Zip : 48066-4989
Country : US
Telephone Number : 586-745-0116
Fax Number :
Provider Business Practice Location Address
First Line : 18303 E 10 MILE RD STE 200
Second Line :
City : ROSEVILLE
State : MI
Zip : 48066-4989
Country : US
Telephone Number : 586-745-0116
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/09/2013
Last Update Date : 09/19/2018

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