Provider Demographics
NPI:1710648472
Name:COULTER, JEFFEREY
Entity Type:Individual
Prefix:
First Name:JEFFEREY
Middle Name:
Last Name:COULTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3104 KING RD
Mailing Address - Street 2:
Mailing Address - City:CHINA
Mailing Address - State:MI
Mailing Address - Zip Code:48054-1428
Mailing Address - Country:US
Mailing Address - Phone:810-285-0902
Mailing Address - Fax:
Practice Address - Street 1:3104 KING RD
Practice Address - Street 2:
Practice Address - City:CHINA
Practice Address - State:MI
Practice Address - Zip Code:48054-1428
Practice Address - Country:US
Practice Address - Phone:810-285-0902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician