Basic Information
| Provider Information | |||||||||
| NPI: | 1912026758 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENNINGS | ||||||||
| FirstName: | MARY ALICE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | SW, CAC1 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JENNINGS | ||||||||
| OtherFirstName: | MARTY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | S.W. CAC1 | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 775 MOORLAND DR | ||||||||
| Address2: | |||||||||
| City: | GROSSE POINTE WOODS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482361128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138862724 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13336 E. WARREN AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482361128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138226940 | ||||||||
| FaxNumber: | 3138226946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1-00266 | MI | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | 6802057046 | MI | X | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.