Provider Demographics
NPI:1467996090
Name:ANDERSON, JEWELETTER MARIE (LMSW, CAADC)
Entity Type:Individual
Prefix:MRS
First Name:JEWELETTER
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LMSW, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 PEARL ST STE 304
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-2663
Mailing Address - Country:US
Mailing Address - Phone:734-720-4888
Mailing Address - Fax:734-720-4884
Practice Address - Street 1:124 PEARL ST STE 304
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2663
Practice Address - Country:US
Practice Address - Phone:734-720-4888
Practice Address - Fax:734-720-4884
Is Sole Proprietor?:No
Enumeration Date:2016-12-16
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010981601041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID00111Medicaid