| Doctor Name: | MISS JENNIFER LEE THEODORE |
| NPI Number: | 1063894509 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LMSW |
| License Number: | 6801092056 |
| Business Practice Address: | 35031 23 Mile Rd New Baltimore, MI - 480473649 |
| Business Phone Number: | 5867255777 |
| Business Fax Number: | |
| Mailing Address: | 35031 23 Mile Rd, NEW BALTIMORE |
| State: | MI |
| Postal Code: | 480473649 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 06/21/2015 |
| NPI Last Update Date: | 06/21/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 6801092056 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |