Provider Demographics
NPI:1083491823
Name:FRAZIER, BEVERLY JACKSON
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:JACKSON
Last Name:FRAZIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14799 DIX TOLEDO RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2507
Mailing Address - Country:US
Mailing Address - Phone:248-686-9634
Mailing Address - Fax:
Practice Address - Street 1:14799 DIX TOLEDO RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2507
Practice Address - Country:US
Practice Address - Phone:248-686-9634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-14
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401004160101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health