Healthcare Provider Details

I. General information

NPI: 1871668038
Provider Name (Legal Business Name): JESSICA LEE JENKINS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 DIVERSON ST SUITE 10 A
ROCHESTER HILLS MI
48307-2273
US

IV. Provider business mailing address

20300 CIVIC CENTER DR SUITE 303
SOUTHFIELD MI
48076-4169
US

V. Phone/Fax

Practice location:
  • Phone: 248-608-9740
  • Fax: 248-608-9752
Mailing address:
  • Phone: 248-559-8190
  • Fax: 248-559-8776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPERMID6301013418L982
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: