Provider Demographics
NPI:1558791095
Name:DEJA, JENNIFER (LLMSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DEJA
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 867
Mailing Address - Street 2:
Mailing Address - City:WHITE CLOUD
Mailing Address - State:MI
Mailing Address - Zip Code:49349-0867
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1049 E. NEWELL ST.
Practice Address - Street 2:
Practice Address - City:WHITE CLOUD
Practice Address - State:MI
Practice Address - Zip Code:49347
Practice Address - Country:US
Practice Address - Phone:231-689-7330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-20
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010947021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical