Provider Demographics
NPI:1417435660
Name:JEWELL, CASSIDY LYNN
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:LYNN
Last Name:JEWELL
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 1:22313 SOLOMON BLVD APT 208
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-5081
Mailing Address - Country:US
Mailing Address - Phone:859-404-3064
Mailing Address - Fax:
Practice Address - Street 1:890 N 10TH ST STE 110
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-6192
Practice Address - Country:US
Practice Address - Phone:888-527-0012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511158781041C0700X, 104100000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid