Basic Information
| Provider Information | |||||||||
| NPI: | 1386373793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAULSEN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2835 ROWAN BLVD | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483292842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487043873 | ||||||||
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| Practice Location | |||||||||
| Address1: | 806 TUURI PL | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485032465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102573705 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2022 | ||||||||
| LastUpdateDate: | 06/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6851114548 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | P425398585746 | 01 | MI | DRIVER LICENSE | OTHER |