Provider Demographics
NPI:1124156088
Name:MICHAEL, JENNIFER (MA TLLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:MA TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3872 KIRKWOOD ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-1130
Mailing Address - Country:US
Mailing Address - Phone:517-750-3928
Mailing Address - Fax:
Practice Address - Street 1:1200 N WEST AVE STE 400
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2180
Practice Address - Country:US
Practice Address - Phone:517-262-0487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL754897103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling