Provider Demographics
NPI:1760292452
Name:KOPNICK, JENNIFER ELAINE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELAINE
Last Name:KOPNICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2911 PONTIAC LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-2681
Mailing Address - Country:US
Mailing Address - Phone:951-505-5465
Mailing Address - Fax:
Practice Address - Street 1:17177 N LAUREL PARK DR STE 131
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3952
Practice Address - Country:US
Practice Address - Phone:734-462-3210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-13
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704318207163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse