Provider Demographics
NPI:1972026482
Name:HIBBARD, JENNIFER (LLMSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HIBBARD
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 JENNER DR
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-1517
Mailing Address - Country:US
Mailing Address - Phone:269-257-1062
Mailing Address - Fax:
Practice Address - Street 1:3285 122ND AVE
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-9511
Practice Address - Country:US
Practice Address - Phone:269-257-1062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511152901041C0700X
106S00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6851115290Medicaid