Basic Information
| Provider Information | |||||||||
| NPI: | 1245597905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOYLE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | KESSIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., L.L.P | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2671 BROOKLYN DR | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481981027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349049935 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 19401 NORTHLINE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347857700 | ||||||||
| FaxNumber: | 7342872074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2012 | ||||||||
| LastUpdateDate: | 07/22/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301015017 | MI | N | Behavioral Health & Social Service Providers | Psychologist | 103TM1800X | 6301015017 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities |
No ID Information.