Provider Demographics
NPI:1043245533
Name:JAMAIL PSYCHOLOGICAL CLINIC PC
Entity Type:Organization
Organization Name:JAMAIL PSYCHOLOGICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMAIL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:810-767-4114
Mailing Address - Street 1:1114 BEACH ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48502-1407
Mailing Address - Country:US
Mailing Address - Phone:810-767-4114
Mailing Address - Fax:810-767-4429
Practice Address - Street 1:1114 BEACH ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48502-1407
Practice Address - Country:US
Practice Address - Phone:810-767-4114
Practice Address - Fax:810-767-4429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009004103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680B545430OtherBCBSM
=========OtherFEDERAL TAX ID
S20299Medicare UPIN
=========OtherFEDERAL TAX ID