Provider Demographics
NPI:1396099628
Name:MAYER, JESSICA JOYCE (MA, LPC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:JOYCE
Last Name:MAYER
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38785 WINGATE DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-3248
Mailing Address - Country:US
Mailing Address - Phone:586-489-9121
Mailing Address - Fax:
Practice Address - Street 1:1125 E MILHAM AVE STE B
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-3096
Practice Address - Country:US
Practice Address - Phone:269-312-1446
Practice Address - Fax:269-775-1079
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-08
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013204101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1396099628Medicaid
MI101YM0800XMedicaid