Provider Demographics
NPI:1295602779
Name:CHILDERS, JAJUANE AKIL LATEEF JR
Entity type:Individual
Prefix:
First Name:JAJUANE
Middle Name:AKIL LATEEF
Last Name:CHILDERS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3165 FIELSTRA DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-4710
Mailing Address - Country:US
Mailing Address - Phone:231-457-5673
Mailing Address - Fax:
Practice Address - Street 1:23800 NORTHWESTERN HWY STE 190
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-7740
Practice Address - Country:US
Practice Address - Phone:248-900-2166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-20
Last Update Date:2025-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician