Provider Demographics
NPI:1609459700
Name:JEROJEIS, FADYA
Entity Type:Individual
Prefix:
First Name:FADYA
Middle Name:
Last Name:JEROJEIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:238 WEDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1020
Practice Address - Country:US
Practice Address - Phone:517-574-6652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2024-03-08
Deactivation Date:2024-02-27
Deactivation Code:
Reactivation Date:2024-03-05
Provider Licenses
StateLicense IDTaxonomies
MI12470966103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician