Provider Demographics
NPI:1669585881
Name:LAST, JEFFREY MICHAEL (PHD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:LAST
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20300 CIVIC CENTER DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-4105
Mailing Address - Country:US
Mailing Address - Phone:248-559-5774
Mailing Address - Fax:248-559-8776
Practice Address - Street 1:20300 CIVIC CENTER DR
Practice Address - Street 2:SUITE 303
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-4105
Practice Address - Country:US
Practice Address - Phone:248-559-5774
Practice Address - Fax:248-559-8776
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003183103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist