Provider Demographics
NPI:1629400353
Name:MACK, JENNIFER CHRISTINA (LMSW)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:CHRISTINA
Last Name:MACK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:CHRISTINA
Other - Last Name:DRISCOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLMSW
Mailing Address - Street 1:1115 BALL AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505
Mailing Address - Country:US
Mailing Address - Phone:616-558-9534
Mailing Address - Fax:
Practice Address - Street 1:1115 BALL AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505
Practice Address - Country:US
Practice Address - Phone:616-558-9534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010954361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical