Provider Demographics
NPI:1003419136
Name:HEAL THYSELF THERAPEUTICS, LLC
Entity Type:Organization
Organization Name:HEAL THYSELF THERAPEUTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:II
Authorized Official - Credentials:LMSW
Authorized Official - Phone:810-434-7933
Mailing Address - Street 1:34326 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-8511
Mailing Address - Country:US
Mailing Address - Phone:810-434-7933
Mailing Address - Fax:
Practice Address - Street 1:1100 CORPORATE OFFICE DR STE 320
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-5002
Practice Address - Country:US
Practice Address - Phone:810-434-7933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-20
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty