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General NPI Number Information
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NPI Number | 1316342447
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Entity Type | Organization
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Legal Business Name | DR. JENNIFER B. MAINKA, LLC
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Dates
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Enumeration Date | 10/31/2014
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Last Update Date | 12/15/2014
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Provider Practice Location Address
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Address Line | 2300 GENOA BUSINESS PARK DR SUITE 160
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City | BRIGHTON
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State | MI
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Zip | 48114-7367
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Country | US
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Telephone | 810-522-0785
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Fax | 810-229-5337
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Provider Business Mailing Address
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Address Line | 2300 GENOA BUSINESS PARK DR SUITE 160
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City | BRIGHTON
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State | MI
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Zip | 48114-7367
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Country | US
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Telephone | 810-522-0785
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Fax | 810-229-5337
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. JENNIFER BOSS MAINKA
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Credential | PH.D.
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Telephone | 248-444-2418
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6301014583
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License Number State | MI
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