Provider Demographics
NPI:1346585692
Name:GOTTS, JENNIFER MICHELLE-HICKOX (MA, TLLP, NCSP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MICHELLE-HICKOX
Last Name:GOTTS
Suffix:
Gender:F
Credentials:MA, TLLP, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30445 NORTHWESTERN HWY STE 330
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30445 NORTHWESTERN HWY STE 330
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3102
Practice Address - Country:US
Practice Address - Phone:248-538-5045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015008103TC0700X
MISP0000000800668103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP39730001Medicare PIN