Provider Demographics
NPI:1710126750
Name:MAYNARD, JESSIE M (LP, PSYD, CAADC)
Entity Type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:M
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:LP, PSYD, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1199 TEAKWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-9734
Mailing Address - Country:US
Mailing Address - Phone:517-881-3055
Mailing Address - Fax:
Practice Address - Street 1:585 JEWETT RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:MI
Practice Address - Zip Code:48854-8729
Practice Address - Country:US
Practice Address - Phone:517-833-8100
Practice Address - Fax:517-676-5207
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-15
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015286103TC0700X, 103TP2701X, 101YM0800X
MIC-00917101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)