Provider Demographics
NPI:1245621689
Name:BOOTH, JESSICA (LMSW)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:BOOTH
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 1:1305 E JOLLY RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-7146
Mailing Address - Country:US
Mailing Address - Phone:517-346-8436
Mailing Address - Fax:
Practice Address - Street 1:1305 E JOLLY RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-7146
Practice Address - Country:US
Practice Address - Phone:517-346-8436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010853321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical