Provider Demographics
NPI:1285735357
Name:DUTTON, JACK A (MA, LPC, LBSW)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:A
Last Name:DUTTON
Suffix:
Gender:M
Credentials:MA, LPC, LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6780 UPPER RD
Mailing Address - Street 2:
Mailing Address - City:MARLETTE
Mailing Address - State:MI
Mailing Address - Zip Code:48453-9560
Mailing Address - Country:US
Mailing Address - Phone:989-635-7852
Mailing Address - Fax:
Practice Address - Street 1:217 E SANILAC RD
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:MI
Practice Address - Zip Code:48471-1383
Practice Address - Country:US
Practice Address - Phone:810-583-0393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401003332101YP2500X
MI6802035127104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker