Provider Demographics
NPI:1295044451
Name:BAUER, JENNIFER (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BAUER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3833 PINE MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-8594
Mailing Address - Country:US
Mailing Address - Phone:616-644-0553
Mailing Address - Fax:
Practice Address - Street 1:3790 30TH ST SE
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1201
Practice Address - Country:US
Practice Address - Phone:616-204-1180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014607103T00000X
MI6301016853103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist