Provider Demographics
NPI:1013320449
Name:URBAN, JACQUELINE (LMSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:URBAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 EAST NEWMAN
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48895
Mailing Address - Country:US
Mailing Address - Phone:517-604-1863
Mailing Address - Fax:
Practice Address - Street 1:137 E NEWMAN RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:MI
Practice Address - Zip Code:48895-9329
Practice Address - Country:US
Practice Address - Phone:517-604-1863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010912191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical