Provider Demographics
NPI:1518576073
Name:ISHAQ, JENNIFER (PSY MA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ISHAQ
Suffix:
Gender:F
Credentials:PSY MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1273 ROSALIE DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-9646
Mailing Address - Country:US
Mailing Address - Phone:810-835-5743
Mailing Address - Fax:
Practice Address - Street 1:1777 AXTELL DR STE 100
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4400
Practice Address - Country:US
Practice Address - Phone:248-862-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009337103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist