Basic Information
| Provider Information | |||||||||
| NPI: | 1679093322 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLS | ||||||||
| FirstName: | JERISHA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LLBSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1536 MARION AVE | ||||||||
| Address2: | |||||||||
| City: | LINCOLN PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481462118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133784120 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2925 RUSSELL ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482074825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133965300 | ||||||||
| FaxNumber: | 3137841003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 104100000X | 6802089492 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.