Provider Demographics
NPI:1790931251
Name:TITUS, JACQUELINE MEZZA (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MEZZA
Last Name:TITUS
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 1:151 PSYCHOLOGY BUILDING
Mailing Address - Street 2:MSU PSYCHOLOGICAL CLINIC
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824
Mailing Address - Country:US
Mailing Address - Phone:517-599-4934
Mailing Address - Fax:
Practice Address - Street 1:151 PSYCHOLOGY BLDG
Practice Address - Street 2:MICHIGAN STATE PSYCHOLOGICAL CLINIC
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-1116
Practice Address - Country:US
Practice Address - Phone:517-599-4934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014282103TC0700X
MI6301013657390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical