Provider Demographics
NPI:1417561945
Name:SUSAN, JENNIFER NICHOLE (MA, LLPC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:NICHOLE
Last Name:SUSAN
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16212 TIMBERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-1655
Mailing Address - Country:US
Mailing Address - Phone:586-744-9902
Mailing Address - Fax:
Practice Address - Street 1:1080 KIRTS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4853
Practice Address - Country:US
Practice Address - Phone:586-744-9902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional