Provider Demographics
NPI:1134859549
Name:FORTUNE, JAMES ALBERT JR
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:ALBERT
Last Name:FORTUNE
Suffix:JR
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 1:7264 N SHELDON RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2150
Mailing Address - Country:US
Mailing Address - Phone:734-787-5872
Mailing Address - Fax:
Practice Address - Street 1:7264 N SHELDON RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2150
Practice Address - Country:US
Practice Address - Phone:734-787-5872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor