Provider Demographics
NPI:1952412322
Name:BEAVERS, JACALYN R
Entity Type:Individual
Prefix:
First Name:JACALYN
Middle Name:R
Last Name:BEAVERS
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 1:29877 TELEGRAPH RD
Mailing Address - Street 2:STE 401
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-7661
Mailing Address - Country:US
Mailing Address - Phone:248-358-5334
Mailing Address - Fax:248-356-7596
Practice Address - Street 1:29877 TELEGRAPH RD
Practice Address - Street 2:STE 401
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-7661
Practice Address - Country:US
Practice Address - Phone:248-358-5334
Practice Address - Fax:248-356-7596
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802083584104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6802083584OtherSTATE LICENSE