Basic Information
| Provider Information | |||||||||
| NPI: | 1902249519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HADDOCK | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6549 TOWN CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483464824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344229340 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 31500 SCHOOLCRAFT RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481501805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344229340 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2013 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801092209 | MI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 6801092209 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.