Provider Demographics
NPI:1043291065
Name:BAILEY, JAN S (LMSW ACSW)
Entity Type:Individual
Prefix:MRS
First Name:JAN
Middle Name:S
Last Name:BAILEY
Suffix:
Gender:F
Credentials:LMSW ACSW
Other - Prefix:MRS
Other - First Name:JEANNETTE
Other - Middle Name:S
Other - Last Name:WEASEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW ACSW
Mailing Address - Street 1:308 S MAUMEE ST
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-2033
Mailing Address - Country:US
Mailing Address - Phone:577-423-6889
Mailing Address - Fax:577-423-6890
Practice Address - Street 1:308 S MAUMEE ST
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-2033
Practice Address - Country:US
Practice Address - Phone:577-423-6889
Practice Address - Fax:577-423-6890
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010169461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM11320Medicare ID - Type Unspecified