Provider Demographics
NPI:1891367439
Name:STEVENS, JESS MATTHEW
Entity Type:Individual
Prefix:MR
First Name:JESS
Middle Name:MATTHEW
Last Name:STEVENS
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 1:2408 CHAMPION WAY
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-4869
Mailing Address - Country:US
Mailing Address - Phone:517-812-4578
Mailing Address - Fax:
Practice Address - Street 1:4287 FIVE OAKS DR
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4214
Practice Address - Country:US
Practice Address - Phone:517-882-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011101271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical