Individual
JENNIFER WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
4226 GREEN LAKE RD, WEST BLOOMFIELD, MI 48323-1139
(248) 404-5616
Mailing address
4226 GREEN LAKE RD, WEST BLOOMFIELD, MI 48323-1139
(248) 404-5616
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
6301014813
MI
Other
Enumeration date
08/29/2012
Last updated
08/29/2012
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