Basic Information
| Provider Information | |||||||||
| NPI: | 1750829263 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRYSTAL | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | PAGE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D., LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 37125 BRENTWOOD CIR | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483311847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483316003 | ||||||||
| FaxNumber: | 3135779628 | ||||||||
| Practice Location | |||||||||
| Address1: | 17940 FARMINGTON RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481524444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006931916 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2017 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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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 | 101YM0800X | 6401005542 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.