Provider Demographics
NPI:1245663111
Name:FALLON, JAY SEAN (LLMSW)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:SEAN
Last Name:FALLON
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30739 NEWPORT DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-3163
Mailing Address - Country:US
Mailing Address - Phone:586-747-1150
Mailing Address - Fax:
Practice Address - Street 1:11111 HALL RD STE 303
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48317-5726
Practice Address - Country:US
Practice Address - Phone:586-997-3153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801095931104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker