Provider Demographics
NPI:1386999472
Name:HANAWALT, JENNIFER (PHD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:HANAWALT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2075 W BIG BEAVER RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-3407
Mailing Address - Country:US
Mailing Address - Phone:248-646-6659
Mailing Address - Fax:248-642-8645
Practice Address - Street 1:2075 W BIG BEAVER RD
Practice Address - Street 2:SUITE 520
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3407
Practice Address - Country:US
Practice Address - Phone:248-646-6659
Practice Address - Fax:248-642-8645
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015459103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical