Provider Demographics
NPI:1588730659
Name:KODRIK, JENNIFER ANN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:KODRIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45177 PRESTBURY RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2979
Mailing Address - Country:US
Mailing Address - Phone:734-453-5603
Mailing Address - Fax:734-453-5619
Practice Address - Street 1:42189 ANN ARBOR RD E
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4370
Practice Address - Country:US
Practice Address - Phone:734-453-5603
Practice Address - Fax:734-453-5619
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013094103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist