Provider Demographics
NPI:1578386850
Name:WALSH, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WALSH
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 1:4125 CROOKED TREE RD SW APT 12
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-5253
Mailing Address - Country:US
Mailing Address - Phone:224-542-0638
Mailing Address - Fax:
Practice Address - Street 1:4125 CROOKED TREE RD SW APT 12
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-5253
Practice Address - Country:US
Practice Address - Phone:224-542-0638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011160551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical