Basic Information
| Provider Information | |||||||||
| NPI: | 1134335581 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WA FOOTE MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ON HOLD | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 67000 | ||||||||
| Address2: | DEPARTMENT 272801 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482672728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5718416913 | ||||||||
| FaxNumber: | 5178416917 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 N EAST AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177884800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WICKENS | ||||||||
| AuthorizedOfficialFirstName: | JEANNE' | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5177884883 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WA FOOTE MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CFO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 104100000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.