Provider Demographics
NPI:1598866485
Name:GODFREY, JEANETTE (PHD)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:GODFREY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29731 NOVA WOODS DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-1996
Mailing Address - Country:US
Mailing Address - Phone:313-622-6904
Mailing Address - Fax:313-622-6904
Practice Address - Street 1:29731 NOVA WOODS DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331
Practice Address - Country:US
Practice Address - Phone:313-622-6904
Practice Address - Fax:313-622-6904
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
MI6301009135103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No174400000XOther Service ProvidersSpecialist