Provider Demographics
NPI:1093930141
Name:IMBAULT, JENNIFER LYNN (MA, LLPC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LYNN
Last Name:IMBAULT
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49461-0304
Mailing Address - Country:US
Mailing Address - Phone:231-730-4330
Mailing Address - Fax:
Practice Address - Street 1:200 HOLTON RD
Practice Address - Street 2:UNIT D
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-3349
Practice Address - Country:US
Practice Address - Phone:231-744-5100
Practice Address - Fax:231-744-5100
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010258101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health