Basic Information
| Provider Information | |||||||||
| NPI: | 1710126750 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYNARD | ||||||||
| FirstName: | JESSIE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | LP, PSYD, CAADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1199 TEAKWOOD CIR | ||||||||
| Address2: | |||||||||
| City: | HASLETT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488409734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178813055 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 585 JEWETT RD | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488548729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178338100 | ||||||||
| FaxNumber: | 5176765207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2009 | ||||||||
| LastUpdateDate: | 08/16/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301015286 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TP2701X | 6301015286 | MI | N | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | 101YM0800X | 6301015286 | MI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | C-00917 | MI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.