Provider Demographics
NPI:1780981514
Name:ANDERSON, JEROME KEITH
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:KEITH
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15003 E JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48230-2013
Mailing Address - Country:US
Mailing Address - Phone:313-874-8715
Mailing Address - Fax:313-874-8717
Practice Address - Street 1:1151 TAYLOR ST STE 570A
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-1732
Practice Address - Country:US
Practice Address - Phone:313-874-8715
Practice Address - Fax:313-874-8717
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801092493101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health