Basic Information
Provider Information | |||||||||
NPI: | 1518300847 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACOB | ||||||||
FirstName: | LAUREN | ||||||||
MiddleName: | BETTY | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, TLLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GRUSHOFF | ||||||||
OtherFirstName: | LAUREN | ||||||||
OtherMiddleName: | BETTY | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MA, TLLP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2351 W. 12 MILE RD. | ||||||||
Address2: |   | ||||||||
City: | BERKLEY | ||||||||
State: | MI | ||||||||
PostalCode: | 480721826 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2485444004 | ||||||||
FaxNumber: | 2485444113 | ||||||||
Practice Location | |||||||||
Address1: | 2351 W. 12 MILE RD. | ||||||||
Address2: |   | ||||||||
City: | BERKLEY | ||||||||
State: | MI | ||||||||
PostalCode: | 480721826 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2485444004 | ||||||||
FaxNumber: | 2485444113 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/17/2013 | ||||||||
LastUpdateDate: | 06/01/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | L2310588 | MI | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 6301015300 | MI | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.