Basic Information
| Provider Information | |||||||||
| NPI: | 1629332572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | DAVIDA | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5426 N PICCADILLY | ||||||||
| Address2: | |||||||||
| City: | WEST BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483221439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488190036 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 22170 W 9 MILE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480336007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483726800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2012 | ||||||||
| LastUpdateDate: | 06/26/2012 | ||||||||
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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 | 104100000X | L2257829 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.