Provider Demographics
NPI:1164656245
Name:BAILEY, JENNIFER L (LMSW)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:BAILEY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:WIEDERHOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:824 HURON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3705
Mailing Address - Country:US
Mailing Address - Phone:810-985-7380
Mailing Address - Fax:
Practice Address - Street 1:824 HURON AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3705
Practice Address - Country:US
Practice Address - Phone:810-985-7380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801082747101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health