Provider Demographics
NPI:1821221631
Name:THELEN, JENNIFER FLACK (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:FLACK
Last Name:THELEN
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:LENORE
Other - Last Name:FLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD, LP
Mailing Address - Street 1:127 N RIVER ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3800
Mailing Address - Country:US
Mailing Address - Phone:810-309-9355
Mailing Address - Fax:
Practice Address - Street 1:127 N RIVER ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3800
Practice Address - Country:US
Practice Address - Phone:810-309-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-26
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013884103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical