Provider Demographics
NPI:1740296664
Name:JAMAIL, SUZANNE (PHD)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:JAMAIL
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 1:1114 BEACH ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48502-1407
Mailing Address - Country:US
Mailing Address - Phone:810-767-4114
Mailing Address - Fax:810-767-4429
Practice Address - Street 1:1114 BEACH ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48502-1407
Practice Address - Country:US
Practice Address - Phone:810-767-4114
Practice Address - Fax:810-767-4429
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009004103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
383681520OtherFEDERAL TAX ID
383681520OtherFEDERAL TAX ID
S20299Medicare UPIN