Provider Demographics
NPI:1952651705
Name:PRICE, JEROME ALLEN (MA)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:ALLEN
Last Name:PRICE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30233 SOUTHFIELD RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-1304
Mailing Address - Country:US
Mailing Address - Phone:248-593-4784
Mailing Address - Fax:
Practice Address - Street 1:30233 SOUTHFIELD RD
Practice Address - Street 2:SUITE 109
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1304
Practice Address - Country:US
Practice Address - Phone:248-593-4784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801014986104100000X
MI4101006072106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist