Provider Demographics
NPI:1194244343
Name:CUNNINGHAM, JESSE (CADC)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48381-1975
Mailing Address - Country:US
Mailing Address - Phone:248-529-6383
Mailing Address - Fax:
Practice Address - Street 1:120 S MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1975
Practice Address - Country:US
Practice Address - Phone:248-529-6383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2-01453101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)