Provider Demographics
NPI:1144312265
Name:JACK, MARY JANE (MSP CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:JACK
Suffix:
Gender:F
Credentials:MSP CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 HEALTH PROFESSIONS BUILDING
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48859-0001
Mailing Address - Country:US
Mailing Address - Phone:989-774-7290
Mailing Address - Fax:989-774-1891
Practice Address - Street 1:1101 HEALTH PROFESSIONS BUILDING
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48859-0001
Practice Address - Country:US
Practice Address - Phone:989-774-7290
Practice Address - Fax:989-774-1891
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIASHA 01088409235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI01088409OtherASHA NUMBER
MI40-4683793Medicaid