Provider Demographics
NPI:1003962572
Name:WELLS, JEANINE B (LLP, MSW)
Entity Type:Individual
Prefix:MRS
First Name:JEANINE
Middle Name:B
Last Name:WELLS
Suffix:
Gender:F
Credentials:LLP, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4905 BERL DR
Mailing Address - Street 2:STE 3
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-2807
Mailing Address - Country:US
Mailing Address - Phone:989-790-5722
Mailing Address - Fax:989-790-7182
Practice Address - Street 1:4905 BERL DR
Practice Address - Street 2:STE 3
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2807
Practice Address - Country:US
Practice Address - Phone:989-790-5722
Practice Address - Fax:989-790-7182
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003292103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP57788OtherMHN EDS CLAIMS
MI1008485OtherMCLAREN HEALTH PLAN
MIXX09699OtherHEALTH PLUS
MIP57788OtherAETNA