Provider Demographics
NPI:1093167207
Name:HUSTON, DEJEANNE
Entity Type:Individual
Prefix:
First Name:DEJEANNE
Middle Name:
Last Name:HUSTON
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 1:29699 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2038
Mailing Address - Country:US
Mailing Address - Phone:248-233-4423
Mailing Address - Fax:248-559-0773
Practice Address - Street 1:29699 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2038
Practice Address - Country:US
Practice Address - Phone:248-233-4423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI069726171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator