Healthcare Provider Details

I. General information

NPI: 1114273174
Provider Name (Legal Business Name): JENNIFER LYNN ROOT MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 06/07/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8725 FAWN CREST DR SE
ALTO MI
49302-9314
US

IV. Provider business mailing address

8725 FAWN CREST DR SE
ALTO MI
49302-9314
US

V. Phone/Fax

Practice location:
  • Phone: 269-501-4223
  • Fax:
Mailing address:
  • Phone: 269-501-4223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401011265
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: