Provider Demographics
NPI:1083671523
Name:NOVELLO, JONATHON JEFFREY (LMSW, ACSW)
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:JEFFREY
Last Name:NOVELLO
Suffix:
Gender:M
Credentials:LMSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 HILLCREST AVENUE
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823
Mailing Address - Country:US
Mailing Address - Phone:517-290-7011
Mailing Address - Fax:
Practice Address - Street 1:525 HILLCREST AVENUE
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823
Practice Address - Country:US
Practice Address - Phone:517-290-7011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801072600104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP90236Medicare UPIN
MIM12270030Medicare ID - Type UnspecifiedWA FOOTE MEMORIAL