Provider Demographics
NPI:1134741283
Name:TERRY, JACK STANLEY
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:STANLEY
Last Name:TERRY
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:PO BOX 530564
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48153-0564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22370 INNSBROOK DR
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-9322
Practice Address - Country:US
Practice Address - Phone:248-719-1791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490067601041C0700X
MI68010631181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI000000000OtherNONE