Basic Information
| Provider Information | |||||||||
| NPI: | 1780981514 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | JEROME | ||||||||
| MiddleName: | KEITH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15003 E JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | GROSSE POINTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482302013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138748715 | ||||||||
| FaxNumber: | 3138748717 | ||||||||
| Practice Location | |||||||||
| Address1: | 1151 TAYLOR ST STE 570A | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482021732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138748715 | ||||||||
| FaxNumber: | 3138748717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2011 | ||||||||
| LastUpdateDate: | 02/14/2011 | ||||||||
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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 | 101YM0800X | 6801092493 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.