Healthcare Provider Details

I. General information

NPI: 1982944203
Provider Name (Legal Business Name): JENNIFER RENE THOMPSON CPSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2013
Last Update Date: 02/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14799 DIX TOLEDO RD
SOUTHGATE MI
48195-2507
US

IV. Provider business mailing address

18710 VAN HORN RD APT 103
WOODHAVEN MI
48183-3800
US

V. Phone/Fax

Practice location:
  • Phone: 734-324-8326
  • Fax:
Mailing address:
  • Phone: 734-925-3896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: