Provider Demographics
NPI:1841457751
Name:MARSHALL, JACQULYN ALBERTA (LMSW)
Entity type:Individual
Prefix:MRS
First Name:JACQULYN
Middle Name:ALBERTA
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MRS
Other - First Name:JACQULYN
Other - Middle Name:ALBERTA
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:PO BOX 250693
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48325-0693
Mailing Address - Country:US
Mailing Address - Phone:248-356-0540
Mailing Address - Fax:248-356-0539
Practice Address - Street 1:22511 TELEGRAPH RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-4115
Practice Address - Country:US
Practice Address - Phone:248-356-0540
Practice Address - Fax:248-356-0539
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010177171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN90370026Medicare PIN