Basic Information
| Provider Information | |||||||||
| NPI: | 1689831331 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILLINGHAM | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LLMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45276 NORTHPORT DR | ||||||||
| Address2: | APT. 6203 | ||||||||
| City: | MACOMB | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480445300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862128295 | ||||||||
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| Practice Location | |||||||||
| Address1: | 35555 GARFIELD RD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480355517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867921654 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2008 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801090091 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.