Provider Demographics
NPI:1154412930
Name:OGILVIE, JEAN LAVONNE (LLP)
Entity type:Individual
Prefix:MS
First Name:JEAN
Middle Name:LAVONNE
Last Name:OGILVIE
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2585
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49081-2585
Mailing Address - Country:US
Mailing Address - Phone:269-381-0150
Mailing Address - Fax:269-373-4720
Practice Address - Street 1:8036 MOORSBRIDGE ROAD
Practice Address - Street 2:SUITE #2
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4417
Practice Address - Country:US
Practice Address - Phone:269-327-1438
Practice Address - Fax:269-327-6454
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009676103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0C910880OtherPROFESSIONAL NUMBER
08913870OtherBLUE CROSS BLUE SHIELD
OTH000Medicare UPIN