Provider Demographics
NPI:1578190815
Name:MOLICA, JEREMY SEAN (LLMSW, CADC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:SEAN
Last Name:MOLICA
Suffix:
Gender:M
Credentials:LLMSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485 M 139
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:MI
Mailing Address - Zip Code:49022
Mailing Address - Country:US
Mailing Address - Phone:269-925-0585
Mailing Address - Fax:269-927-1326
Practice Address - Street 1:24 N. SAINT JOSEPH AVENUE SUITE A & G
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2622
Practice Address - Country:US
Practice Address - Phone:269-925-0585
Practice Address - Fax:269-927-1326
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511165371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical