Provider Demographics
NPI:1073972774
Name:CLEMENTS, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CLEMENTS
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 1:3766 STAMFORD CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-2953
Mailing Address - Country:US
Mailing Address - Phone:248-704-4751
Mailing Address - Fax:
Practice Address - Street 1:4301 STRETTON FARM CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5564
Practice Address - Country:US
Practice Address - Phone:248-704-4751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-23
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401000275103TC0700X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical