Basic Information
| Provider Information | |||||||||
| NPI: | 1740307982 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENNINGS | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | DORIS | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MA,LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1110 HOPE ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495061563 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1331 LAKE DR SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495061674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164597215 | ||||||||
| FaxNumber: | 6164510020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401004387 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.