Basic Information
| Provider Information | |||||||||
| NPI: | 1326418021 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEANE | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19317 ANTAGO ST | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481522511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132892960 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8623 N WAYNE RD | ||||||||
| Address2: | |||||||||
| City: | WESTLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481851137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344250636 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2015 | ||||||||
| LastUpdateDate: | 04/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401014535 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1326418021 | 05 | MI | MEDICAID |