Provider Demographics
NPI:1578994570
Name:MERRILL, JESSICA (LLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MERRILL
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4461 ASTER BLVD
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-6524
Mailing Address - Country:US
Mailing Address - Phone:517-294-3376
Mailing Address - Fax:
Practice Address - Street 1:4461 ASTER BLVD
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-6524
Practice Address - Country:US
Practice Address - Phone:517-294-3376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-02
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015712103T00000X
106S00000X
MI6361005723103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician