Provider Demographics
NPI:1376529198
Name:WHITE, JAMES JR (PHD, NP)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:WHITE
Suffix:JR
Gender:M
Credentials:PHD, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 N CASS LAKE RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-2370
Mailing Address - Country:US
Mailing Address - Phone:248-681-0623
Mailing Address - Fax:
Practice Address - Street 1:950 N CASS LAKE RD
Practice Address - Street 2:SUITE 107
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-2370
Practice Address - Country:US
Practice Address - Phone:248-681-0623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704156612363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4368404Medicaid
MIE26216Medicare UPIN
MIOM57870Medicare ID - Type Unspecified