Provider Demographics
NPI:1952732877
Name:DEVIVO, JENNIFER CLAIRE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CLAIRE
Last Name:DEVIVO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:NOESEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW, ACSW
Mailing Address - Street 1:619 MILL ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48381-2270
Mailing Address - Country:US
Mailing Address - Phone:734-417-4287
Mailing Address - Fax:734-369-3291
Practice Address - Street 1:3300 WASHTENAW AVE STE 270
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5188
Practice Address - Country:US
Practice Address - Phone:734-417-4287
Practice Address - Fax:734-369-3291
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010772341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical