Provider Demographics
NPI:1285219964
Name:PUCKETT, JULIA (PHD)
Entity Type:Individual
Prefix:DR
First Name:JULIA
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JAE
Other - Middle Name:
Other - Last Name:PUCKETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:812 E JOLLY RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-6818
Mailing Address - Country:US
Mailing Address - Phone:517-346-8200
Mailing Address - Fax:
Practice Address - Street 1:2929 COVINGTON CT
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-4941
Practice Address - Country:US
Practice Address - Phone:517-798-6745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017827103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical