Basic Information
| Provider Information | |||||||||
| NPI: | 1215473830 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEMENT | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LLCP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEBB | ||||||||
| OtherFirstName: | JENNY | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 704 EMMET ST. | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313475511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 704 EMMET ST. | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313475511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2017 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 6401018729 | MI | N | Behavioral Health & Social Service Providers | Counselor | 106S00000X | N | 101YP2500X | 6401018729 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.