Provider Demographics
NPI:1083266407
Name:BISHOP, JUSTIN JEREMY
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:JEREMY
Last Name:BISHOP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9483 GALATIAN DR
Mailing Address - Street 2:
Mailing Address - City:WHITMORE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48189-9716
Mailing Address - Country:US
Mailing Address - Phone:734-646-8426
Mailing Address - Fax:
Practice Address - Street 1:1200 N WEST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2179
Practice Address - Country:US
Practice Address - Phone:517-780-3350
Practice Address - Fax:517-789-1286
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020903981041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical