Individual
JIMMY IVY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
7310 WOODWARD AVE, DETROIT, MI 48202-3165
(313) 230-8504
Mailing address
25610 W 12 MILE RD, SOUTHFIELD, MI 48034-8030
(517) 962-6256
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
6801113515
MI
1041C0700X
Clinical Social Worker
6801102170
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
L100414454389
—
MI
Enumeration date
05/11/2018
Last updated
08/03/2022
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