Healthcare Provider Details

I. General information

NPI: 1407290711
Provider Name (Legal Business Name): JENNIFER LYN JOHNSON MS LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13938 M GIBRALTAR RD
GIBRALTAR MI
48173-9711
US

IV. Provider business mailing address

13938 M GIBRALTAR RD
GIBRALTAR MI
48173-9711
US

V. Phone/Fax

Practice location:
  • Phone: 313-484-3211
  • Fax: 313-710-4520
Mailing address:
  • Phone: 313-484-3211
  • Fax: 313-710-4520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301010450
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: