Provider Demographics
NPI:1598991986
Name:MAISE-CORMIER, JENNIFER ROSE (LPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:MAISE-CORMIER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16532 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-2174
Mailing Address - Country:US
Mailing Address - Phone:248-672-1712
Mailing Address - Fax:
Practice Address - Street 1:16532 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-2174
Practice Address - Country:US
Practice Address - Phone:248-672-1712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-31
Last Update Date:2009-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401002070101YA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)