Healthcare Provider Details

I. General information

NPI: 1780338137
Provider Name (Legal Business Name): JENNIFER KEUTEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2022
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2170 E BIG BEAVER RD STE B
TROY MI
48083-2375
US

IV. Provider business mailing address

2170 E BIG BEAVER RD STE B
TROY MI
48083-2375
US

V. Phone/Fax

Practice location:
  • Phone: 248-663-8162
  • Fax:
Mailing address:
  • Phone: 248-663-8162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6802071995
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: