Provider Demographics
NPI:1700125994
Name:WASSON, JENNIFER (LLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WASSON
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 E JOLLY RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-6818
Mailing Address - Country:US
Mailing Address - Phone:517-346-8200
Mailing Address - Fax:
Practice Address - Street 1:3200 REMY DR
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48906-2759
Practice Address - Country:US
Practice Address - Phone:517-323-9558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014430103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist