Provider Demographics
NPI:1700238128
Name:MCCULLOCH, JENNIFER (LMSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 PAULINE BLVD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-5003
Mailing Address - Country:US
Mailing Address - Phone:734-994-9466
Mailing Address - Fax:
Practice Address - Street 1:1955 PAULINE BLVD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-5003
Practice Address - Country:US
Practice Address - Phone:734-994-9466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-09
Last Update Date:2016-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010870661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical