Basic Information
| Provider Information | |||||||||
| NPI: | 1770822215 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVERT | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | L.M.S.W. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | SUE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | L.M.S.W. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 622 E GRAND RIVER AVE | ||||||||
| Address2: | |||||||||
| City: | HOWELL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488432329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5175480081 | ||||||||
| FaxNumber: | 5175480498 | ||||||||
| Practice Location | |||||||||
| Address1: | 622 E GRAND RIVER AVE | ||||||||
| Address2: | |||||||||
| City: | HOWELL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488432329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5175480081 | ||||||||
| FaxNumber: | 5175480498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2013 | ||||||||
| LastUpdateDate: | 01/31/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801089167 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.