Provider Demographics
NPI:1558718502
Name:BEAVERS, JACQUELINE MARIA (LMSW)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:MARIA
Last Name:BEAVERS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19300 APPOLINE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1215
Mailing Address - Country:US
Mailing Address - Phone:586-339-2660
Mailing Address - Fax:734-207-5326
Practice Address - Street 1:89 E EDSEL FORD FWY STE 200
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3742
Practice Address - Country:US
Practice Address - Phone:586-339-2660
Practice Address - Fax:734-207-5326
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011097211041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI68011109721OtherLMSW LICENSE