Provider Demographics
NPI:1932656030
Name:MIYAMOTO, JENNIFER (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:MIYAMOTO
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 1:524 E MILHAM AVE STE B
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-1473
Mailing Address - Country:US
Mailing Address - Phone:269-264-4920
Mailing Address - Fax:
Practice Address - Street 1:524 E MILHAM AVE STE B
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1473
Practice Address - Country:US
Practice Address - Phone:269-264-4920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011143791041C0700X
MI6801102995104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker