Provider Demographics
NPI:1306009196
Name:WOODBURN, JACK D (LPC)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:D
Last Name:WOODBURN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 MILITARY ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-5418
Mailing Address - Country:US
Mailing Address - Phone:810-984-5575
Mailing Address - Fax:810-984-6433
Practice Address - Street 1:1101 MILITARY ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5418
Practice Address - Country:US
Practice Address - Phone:810-984-5575
Practice Address - Fax:810-984-6433
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401000326101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional