Provider Demographics
NPI:1578921193
Name:BUYSSE, JENNIFER
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:BUYSSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6749 BUCKHORN ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-3316
Mailing Address - Country:US
Mailing Address - Phone:269-599-0849
Mailing Address - Fax:
Practice Address - Street 1:6749 BUCKHORN ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-3316
Practice Address - Country:US
Practice Address - Phone:269-599-8049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007982101YP2500X, 101Y00000X, 101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool