Active NPI
Jennifer Wallace
- Psychologist
- West Bloomfield, MI
National Provider Identifier
1295083897
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychologist
- License
- 6301014813
- Practice address
- 4226 Green Lake Rd
West Bloomfield, MI 48323-1139 - Phone
- (248) 404-5616
- NPI assigned
- Aug 29, 2012
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | 6301014813 | MI | Primary |
Addresses
Primary practice location
4226 Green Lake Rd
West Bloomfield, MI 48323-1139
Mailing address
4226 Green Lake Rd
West Bloomfield, MI 48323-1139
Phone (248) 404-5616
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 6301014813 | MI | MD | Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1346198400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1346198400000",
"number": "1295083897",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4226 GREEN LAKE RD",
"city": "WEST BLOOMFIELD",
"state": "MI",
"postal_code": "483231139",
"telephone_number": "248-404-5616"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4226 GREEN LAKE RD",
"city": "WEST BLOOMFIELD",
"state": "MI",
"postal_code": "483231139",
"telephone_number": "248-404-5616"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "JENNIFER",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2012-08-29",
"last_updated": "2012-08-29",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "MI",
"license": "6301014813",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in West Bloomfield, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 29, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.