Provider Demographics
NPI:1164002176
Name:SMALL, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3316 KENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-3761
Mailing Address - Country:US
Mailing Address - Phone:989-750-3646
Mailing Address - Fax:
Practice Address - Street 1:3316 KENTWOOD DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-3761
Practice Address - Country:US
Practice Address - Phone:989-750-3646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011040351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical