Provider Demographics
NPI:1932382397
Name:DESCHRYVER, JENNIFER (PSYD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DESCHRYVER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18915 DORIS ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1921
Mailing Address - Country:US
Mailing Address - Phone:248-890-4077
Mailing Address - Fax:
Practice Address - Street 1:4120 W MAPLE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48301-3010
Practice Address - Country:US
Practice Address - Phone:248-890-4077
Practice Address - Fax:248-855-4530
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-07
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011358103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI68-0-F3-0385-0OtherBCBS