Provider Demographics
NPI:1609309004
Name:WILLIS, JEMINA MARIE (BA)
Entity Type:Individual
Prefix:MS
First Name:JEMINA
Middle Name:MARIE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9340 E PICKWICK CIR
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-3854
Mailing Address - Country:US
Mailing Address - Phone:313-685-8524
Mailing Address - Fax:
Practice Address - Street 1:9340 E PICKWICK CIR
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3854
Practice Address - Country:US
Practice Address - Phone:313-685-8524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)