Organization
MCLAREN BAY REGION
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DANIELLE C JACKS PORTER (CFO)
(989) 894-3838
Entity
Organization
Contact information
Practice address
1480 W CENTER RD, ESSEXVILLE, MI 48732
(989) 895-4625
(989) 895-4626
Mailing address
1900 COLUMBUS AVE, BAY CITY, MI 48708-6831
(989) 894-3000
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
—
—
103TC0700X
Clinical Psychologist
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5008702430
BLUE CROSS BLUE SHIELD
MI
Enumeration date
02/05/2007
Last updated
08/07/2018
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