Provider Demographics
NPI:1285100552
Name:CRISWELL, JAKITA M
Entity type:Individual
Prefix:
First Name:JAKITA
Middle Name:M
Last Name:CRISWELL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26345 W 7 MILE RD APT 230
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-1915
Mailing Address - Country:US
Mailing Address - Phone:313-424-3670
Mailing Address - Fax:
Practice Address - Street 1:29260 FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1161
Practice Address - Country:US
Practice Address - Phone:947-622-8944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4151001011106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist