Provider Demographics
NPI:1316342447
Name:DR. JENNIFER B. MAINKA, LLC
Entity type:Organization
Organization Name:DR. JENNIFER B. MAINKA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOSS
Authorized Official - Last Name:MAINKA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:248-444-2418
Mailing Address - Street 1:2300 GENOA BUSINESS PARK DR
Mailing Address - Street 2:SUITE 160
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-7367
Mailing Address - Country:US
Mailing Address - Phone:810-522-0785
Mailing Address - Fax:810-229-5337
Practice Address - Street 1:2300 GENOA BUSINESS PARK DR
Practice Address - Street 2:SUITE 160
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-7367
Practice Address - Country:US
Practice Address - Phone:810-522-0785
Practice Address - Fax:810-229-5337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-31
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014583103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty