Provider Demographics
NPI:1255856142
Name:DRAKE, JESSICA JUNE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JUNE
Last Name:DRAKE
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 1:9004 ROCKLAND
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-1888
Mailing Address - Country:US
Mailing Address - Phone:605-759-4385
Mailing Address - Fax:
Practice Address - Street 1:595 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1775
Practice Address - Country:US
Practice Address - Phone:605-759-4385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TB0200X, 103T00000X, 390200000X
MI6361007695103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program