Provider Demographics
NPI:1952171555
Name:JARVIS, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:JARVIS
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 1:11275 OAK LN APT 1302
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48111-1492
Mailing Address - Country:US
Mailing Address - Phone:313-319-6923
Mailing Address - Fax:
Practice Address - Street 1:11275 OAK LN APT 1302
Practice Address - Street 2:
Practice Address - City:VAN BUREN TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48111-1492
Practice Address - Country:US
Practice Address - Phone:313-319-6923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000464103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical