Provider Demographics
NPI:1245636588
Name:WELLS, JEFFREY (BS, LBSW, CADC, QMHP)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:WELLS
Suffix:
Gender:M
Credentials:BS, LBSW, CADC, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 AMES ST
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-6760
Mailing Address - Country:US
Mailing Address - Phone:989-450-4120
Mailing Address - Fax:
Practice Address - Street 1:201 MULHOLLAND ST
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-7693
Practice Address - Country:US
Practice Address - Phone:989-497-1304
Practice Address - Fax:989-497-1321
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802080976104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker