Provider Demographics
NPI:1225532583
Name:COLE, JENNIFER WELCH
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:WELCH
Last Name:COLE
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 1:205 MAPLEWOOD CT UNIT 1
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1867
Mailing Address - Country:US
Mailing Address - Phone:810-522-4718
Mailing Address - Fax:
Practice Address - Street 1:41700 GARDENBROOK RD STE 110
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1320
Practice Address - Country:US
Practice Address - Phone:248-460-9367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801111352104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1225532583Medicaid