Provider Demographics
NPI:1972286136
Name:JENNE, JUDY LYN (MA, LLPC)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:LYN
Last Name:JENNE
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6580 CREEKSTONE LN SW APT 101
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-7868
Mailing Address - Country:US
Mailing Address - Phone:616-915-5572
Mailing Address - Fax:
Practice Address - Street 1:5020 E BELTLINE AVE NE STE 202
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6869
Practice Address - Country:US
Practice Address - Phone:616-439-1866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451017415101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health