Provider Demographics
NPI:1548332745
Name:EVANS, JEFFREY E (PHD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:E
Last Name:EVANS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PL
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:325 EAST EISENHOWER PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-5744
Practice Address - Country:US
Practice Address - Phone:734-936-7052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002580103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIR66773Medicare UPIN
MI0H16185003Medicare ID - Type Unspecified