MEDICARE: MR. JESSE WASHINGTON JR. BA,CAC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1851423768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JESSE WASHINGTON JR. BA,CAC

Provider Business Mailing Address
First Line	:	17359 LAHSER RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48219-2333
Country	:	US
Telephone Number	:	313-534-3658
Fax Number	:

Provider Business Practice Location Address
First Line	:	5470 CHENE ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48211-2746
Country	:	US
Telephone Number	:	313-875-5521
Fax Number	:	313-267-0549

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

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	07/08/2007

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