Provider Demographics
NPI:1679743181
Name:HARRELL, JESSICA PURTAN (PHD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:PURTAN
Last Name:HARRELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5665 W MAPLE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3741
Mailing Address - Country:US
Mailing Address - Phone:248-767-5985
Mailing Address - Fax:248-626-8836
Practice Address - Street 1:5665 W MAPLE RD
Practice Address - Street 2:SUITE A
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3741
Practice Address - Country:US
Practice Address - Phone:248-767-5985
Practice Address - Fax:248-626-8836
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010406103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral