Provider Demographics
NPI:1326747684
Name:KOPKE, JANELL KAYE (CCAR)
Entity Type:Individual
Prefix:
First Name:JANELL
Middle Name:KAYE
Last Name:KOPKE
Suffix:
Gender:F
Credentials:CCAR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 N SAGINAW RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-3350
Mailing Address - Country:US
Mailing Address - Phone:989-631-0241
Mailing Address - Fax:
Practice Address - Street 1:1213 E ISABELLA RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-8344
Practice Address - Country:US
Practice Address - Phone:989-492-2023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility