Healthcare Provider Details

I. General information

NPI: 1063725489
Provider Name (Legal Business Name): JENNIFER MICHAEL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 E RIDGE RD
ROCHESTER NY
14621-1229
US

IV. Provider business mailing address

490 E RIDGE RD
ROCHESTER NY
14621-1229
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-2500
  • Fax: 585-922-2646
Mailing address:
  • Phone: 585-922-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number72 082247
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number083950
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: