Provider Demographics
NPI:1215377171
Name:EVANS, JENISE MAE (BSW)
Entity Type:Individual
Prefix:
First Name:JENISE
Middle Name:MAE
Last Name:EVANS
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:JENISE
Other - Middle Name:MAE
Other - Last Name:TOWNSEND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSW
Mailing Address - Street 1:10182 FOREST RD
Mailing Address - Street 2:
Mailing Address - City:GLADWIN
Mailing Address - State:MI
Mailing Address - Zip Code:48624-8811
Mailing Address - Country:US
Mailing Address - Phone:989-429-4770
Mailing Address - Fax:
Practice Address - Street 1:10182 FOREST RD
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-8811
Practice Address - Country:US
Practice Address - Phone:989-429-4770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802086547104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6802086547Medicaid