Provider Demographics
NPI:1720439896
Name:MATTHEWS, JENNIFER
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 LEINBACH AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0035
Mailing Address - Country:US
Mailing Address - Phone:248-495-0684
Mailing Address - Fax:
Practice Address - Street 1:29623 NORTHWESTERN HWY STE 5
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1076
Practice Address - Country:US
Practice Address - Phone:248-495-0684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014902101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional