Provider Demographics
NPI:1770171118
Name:HIBBS, JAMIE (MS, TLLP)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:HIBBS
Suffix:
Gender:F
Credentials:MS, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 GRISWOLD STREET SUITE 111 #306
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226
Mailing Address - Country:US
Mailing Address - Phone:734-648-6353
Mailing Address - Fax:
Practice Address - Street 1:1307 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-2217
Practice Address - Country:US
Practice Address - Phone:734-451-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009227103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical