Provider Demographics
NPI:1568415545
Name:HURST, JACQUELINE TERRY (LMSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:TERRY
Last Name:HURST
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 1:485 ROCK CREEK DR.
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104
Mailing Address - Country:US
Mailing Address - Phone:734-662-9469
Mailing Address - Fax:
Practice Address - Street 1:15370 LEVAN RD.
Practice Address - Street 2:STE 2 LIVONIA COUNSELING CENTER
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154
Practice Address - Country:US
Practice Address - Phone:734-744-0170
Practice Address - Fax:734-744-0171
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0751341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07300075134LIMedicaid
NY07300075134LIMedicaid
NYP73794Medicare UPIN