Provider Demographics
NPI:1417111386
Name:MAINKA, JENNIFER BOSS (MS, LLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BOSS
Last Name:MAINKA
Suffix:
Gender:F
Credentials:MS, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 W MAIN ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-1591
Mailing Address - Country:US
Mailing Address - Phone:810-227-6218
Mailing Address - Fax:810-227-6982
Practice Address - Street 1:324 W MAIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-1591
Practice Address - Country:US
Practice Address - Phone:810-227-6218
Practice Address - Fax:810-227-6982
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013056103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical