Provider Demographics
NPI:1376893909
Name:JEMISON, SYREETA DANIELLE
Entity Type:Individual
Prefix:MISS
First Name:SYREETA
Middle Name:DANIELLE
Last Name:JEMISON
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 1:2441 LAKESHORE BLVD. #729
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198
Mailing Address - Country:US
Mailing Address - Phone:313-394-9352
Mailing Address - Fax:
Practice Address - Street 1:35300 NANKIN BLVD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-7222
Practice Address - Country:US
Practice Address - Phone:734-261-1842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010948361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical