Provider Demographics
NPI:1356635403
Name:JOUBERT, GERALD DUANE (LBSW)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:DUANE
Last Name:JOUBERT
Suffix:
Gender:M
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 144TH AVE
Mailing Address - Street 2:
Mailing Address - City:DORR
Mailing Address - State:MI
Mailing Address - Zip Code:49323-9748
Mailing Address - Country:US
Mailing Address - Phone:616-902-4731
Mailing Address - Fax:616-527-0538
Practice Address - Street 1:375 APPLE TREE DR
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-7506
Practice Address - Country:US
Practice Address - Phone:616-527-1790
Practice Address - Fax:616-527-0538
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802064503104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1715928Medicaid