Provider Demographics
NPI:1942721725
Name:WELLS, JACQUELINE MONZELL
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MONZELL
Last Name:WELLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:383 KEELSON DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-3077
Mailing Address - Country:US
Mailing Address - Phone:313-971-6025
Mailing Address - Fax:
Practice Address - Street 1:19321 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2004
Practice Address - Country:US
Practice Address - Phone:313-586-2618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-30
Last Update Date:2017-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI727960Medicaid