Provider Demographics
NPI:1710126750
Name:MAYNARD, JESSIE M (LP, PSYD, CAADC)
Entity type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:M
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:LP, PSYD, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1199 TEAKWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-9734
Mailing Address - Country:US
Mailing Address - Phone:202-630-2790
Mailing Address - Fax:
Practice Address - Street 1:1199 TEAKWOOD CIR
Practice Address - Street 2:
Practice Address - City:HASLETT
Practice Address - State:MI
Practice Address - Zip Code:48840-9734
Practice Address - Country:US
Practice Address - Phone:202-630-2790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-15
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC-00917101YA0400X
MI6301015286101YM0800X, 103TP2701X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy