Provider Demographics
NPI:1912026758
Name:JENNINGS, MARY ALICE (SW, CAC1)
Entity Type:Individual
Prefix:MR
First Name:MARY ALICE
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:SW, CAC1
Other - Prefix:MRS
Other - First Name:MARTY
Other - Middle Name:
Other - Last Name:JENNINGS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SW CAC1
Mailing Address - Street 1:775 MOORLAND DR
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1128
Mailing Address - Country:US
Mailing Address - Phone:313-886-2724
Mailing Address - Fax:
Practice Address - Street 1:13336 E. WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-1128
Practice Address - Country:US
Practice Address - Phone:313-822-6940
Practice Address - Fax:313-822-6946
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-00266101YA0400X
MI6802057046104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker