Provider Demographics
NPI:1407352610
Name:TIPTON, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:TIPTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8106 E JEFFERSON AVE APT D307
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-8055
Mailing Address - Country:US
Mailing Address - Phone:616-378-0036
Mailing Address - Fax:
Practice Address - Street 1:7310 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3165
Practice Address - Country:US
Practice Address - Phone:313-896-1444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
106S00000X, 247200000X, 390200000X
MI6362009753103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program