Provider Demographics
NPI:1508350323
Name:PRANTERA, JENNIFER (LPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PRANTERA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45863 WATERSIDE DR APT 9311
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-5340
Mailing Address - Country:US
Mailing Address - Phone:158-694-6759
Mailing Address - Fax:
Practice Address - Street 1:45863 WATERSIDE DR APT 9311
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-5340
Practice Address - Country:US
Practice Address - Phone:158-694-6759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010796101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor