Provider Demographics
NPI:1306380845
Name:FETTES, JACQUELINE NICOLE
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:FETTES
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 1:134 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:CROSWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48422-1112
Mailing Address - Country:US
Mailing Address - Phone:810-712-9030
Mailing Address - Fax:
Practice Address - Street 1:400 STODDARD RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MI
Practice Address - Zip Code:48062-2505
Practice Address - Country:US
Practice Address - Phone:810-392-2167
Practice Address - Fax:810-392-2057
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-16
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist