Provider Demographics
NPI:1437640687
Name:THE SOURCE COUNSELING, CASE MANAGEMENT AND CONSULTATION
Entity Type:Organization
Organization Name:THE SOURCE COUNSELING, CASE MANAGEMENT AND CONSULTATION
Other - Org Name:THE SOURCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:313-544-3513
Mailing Address - Street 1:18007 JULIANA AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3205
Mailing Address - Country:US
Mailing Address - Phone:313-544-3513
Mailing Address - Fax:
Practice Address - Street 1:29277 SOUTHFIELD RD STE C
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1922
Practice Address - Country:US
Practice Address - Phone:313-409-8073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013761101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty