MEDICARE: ANGELA JO DOUGLASS LLMSW

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	6851120816

General Provider Information

NPI Number	:	1871444604
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA JO DOUGLASS LLMSW

Provider Business Mailing Address
First Line	:	1354 BALDWIN ST
Second Line	:
City	:	JENISON
State	:	MI
Zip	:	49428-8937
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1354 BALDWIN ST
Second Line	:
City	:	JENISON
State	:	MI
Zip	:	49428-8937
Country	:	US
Telephone Number	:	313-530-8055
Fax Number	:

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

Provider Enumeration Date	:	02/06/2026
Last Update Date	:	02/06/2026

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