Provider Demographics
NPI:1962971705
Name:WEST, JENNIFER Y (MA, TLLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:Y
Last Name:WEST
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19322 MACARTHUR
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-2608
Mailing Address - Country:US
Mailing Address - Phone:313-401-7786
Mailing Address - Fax:
Practice Address - Street 1:1777 AXTELL DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4404
Practice Address - Country:US
Practice Address - Phone:248-613-5377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-23
Last Update Date:2018-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016581103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist