MEDICARE: DR. JILL LESLIE KOFENDER PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6301012830	MI
2	103T00000X	Psychologist	6301012830	MI

General Provider Information

NPI Number	:	1912107020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JILL LESLIE KOFENDER PHD

Provider Business Mailing Address
First Line	:	5119 HIGHLAND RD # 192
Second Line	:
City	:	WATERFORD
State	:	MI
Zip	:	48327-1915
Country	:	US
Telephone Number	:	248-867-8766
Fax Number	:	248-669-1925

Provider Business Practice Location Address
First Line	:	5119 HIGHLAND RD # 192
Second Line	:
City	:	WATERFORD
State	:	MI
Zip	:	48327-1915
Country	:	US
Telephone Number	:	248-867-8766
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2007
Last Update Date	:	10/31/2024

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