Basic Information
| Provider Information | |||||||||
| NPI: | 1861840571 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KISSE | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1840 OLD TOWN AVE | ||||||||
| Address2: | |||||||||
| City: | WEST BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482852345 | ||||||||
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| Practice Location | |||||||||
| Address1: | 30000 HIVELEY ROAD | ||||||||
| Address2: | |||||||||
| City: | INKSTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347283400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2016 | ||||||||
| LastUpdateDate: | 06/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801099406 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.