Provider Demographics
NPI:1790501369
Name:FARHAT, JAZELLE
Entity type:Individual
Prefix:
First Name:JAZELLE
Middle Name:
Last Name:FARHAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26327 TENNANT ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3704
Mailing Address - Country:US
Mailing Address - Phone:313-971-4592
Mailing Address - Fax:
Practice Address - Street 1:26327 TENNANT ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-3704
Practice Address - Country:US
Practice Address - Phone:313-971-4592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-28
Last Update Date:2024-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician