Provider Demographics
NPI:1316768278
Name:RICHARDSON, JAELLE MACKENZIE (LMSW)
Entity type:Individual
Prefix:
First Name:JAELLE
Middle Name:MACKENZIE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:JAELLE
Other - Middle Name:MACKENZIE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:28514 LINCOLNVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-5248
Mailing Address - Country:US
Mailing Address - Phone:517-250-2270
Mailing Address - Fax:
Practice Address - Street 1:28514 LINCOLNVIEW DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-5248
Practice Address - Country:US
Practice Address - Phone:517-250-2270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-22
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010958291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical