Provider Demographics
NPI:1760140677
Name:JERECKOS, JENNIFER (LLMSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JERECKOS
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CLAIR ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-1707
Mailing Address - Country:US
Mailing Address - Phone:586-565-0039
Mailing Address - Fax:
Practice Address - Street 1:340 N MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1250
Practice Address - Country:US
Practice Address - Phone:734-335-0028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511051541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty