Provider Demographics
NPI:1356907372
Name:SULLIVAN, JAIMIE ELIZABETH (LLBSW)
Entity type:Individual
Prefix:
First Name:JAIMIE
Middle Name:ELIZABETH
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LLBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8415 SHIRLEY CT APT 11
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4764
Mailing Address - Country:US
Mailing Address - Phone:586-907-4369
Mailing Address - Fax:
Practice Address - Street 1:8415 SHIRLEY CT APT 11
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4764
Practice Address - Country:US
Practice Address - Phone:586-907-4369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician