Provider Demographics
NPI:1467960922
Name:MALZON, JEREMY MICHAEL
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:MICHAEL
Last Name:MALZON
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 1:1806 RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:BARODA
Mailing Address - State:MI
Mailing Address - Zip Code:49101-9768
Mailing Address - Country:US
Mailing Address - Phone:715-644-8069
Mailing Address - Fax:
Practice Address - Street 1:1901 NILES AVE STE 102
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-1615
Practice Address - Country:US
Practice Address - Phone:269-982-7200
Practice Address - Fax:269-982-0202
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016442101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional