Provider Demographics
NPI:1912107020
Name:KOFENDER, JILL LESLIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:LESLIE
Last Name:KOFENDER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:LESLIE
Other - Last Name:SCHRAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:5640 WEST MAPLE RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3718
Mailing Address - Country:US
Mailing Address - Phone:248-867-8766
Mailing Address - Fax:248-669-1925
Practice Address - Street 1:5640 WEST MAPLE RD
Practice Address - Street 2:SUITE 205
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3718
Practice Address - Country:US
Practice Address - Phone:248-867-8766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012830103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical