Provider Demographics
NPI:1386964278
Name:FENTON WELLNESS
Entity type:Organization
Organization Name:FENTON WELLNESS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LENORE
Authorized Official - Last Name:FLACK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:810-309-9355
Mailing Address - Street 1:127 N RIVER ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3800
Mailing Address - Country:US
Mailing Address - Phone:810-309-9355
Mailing Address - Fax:
Practice Address - Street 1:127 N RIVER ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3800
Practice Address - Country:US
Practice Address - Phone:810-309-9355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-03
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401006094101Y00000X
MI6301014240103T00000X
MI6301005725103T00000X
MI6301002268103T00000X
MI6801006671104100000X
MI6801019131104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty