Healthcare Provider Details

I. General information

NPI: 1851588420
Provider Name (Legal Business Name): JENNIFER D KOWALKOWSKI PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16815 E JEFFERSON AVE STE 120
GROSSE POINTE MI
48230-1923
US

IV. Provider business mailing address

26901 BEAUMONT BLVD
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 586-498-4400
  • Fax:
Mailing address:
  • Phone: 248-577-9205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6801012939
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301015316
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: