Provider Demographics
NPI:1548649502
Name:BAKER, JESSICA (MLP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:MLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-1277
Mailing Address - Country:US
Mailing Address - Phone:313-656-4052
Mailing Address - Fax:313-656-4053
Practice Address - Street 1:315 N CENTER ST
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1277
Practice Address - Country:US
Practice Address - Phone:313-656-4052
Practice Address - Fax:313-656-4053
Is Sole Proprietor?:No
Enumeration Date:2015-05-23
Last Update Date:2024-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016857103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical