Provider Demographics
NPI:1427621598
Name:MADDOCK, JAY MICHAEL (MA, LPC)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:MICHAEL
Last Name:MADDOCK
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5340 HOLIDAY TER STE 13
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-2181
Mailing Address - Country:US
Mailing Address - Phone:269-372-4140
Mailing Address - Fax:
Practice Address - Street 1:5340 HOLIDAY TER STE 13
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2181
Practice Address - Country:US
Practice Address - Phone:269-372-4140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401223782101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional