Provider Demographics
NPI:1922297076
Name:JENTONS, RICKY LEE (MALLP)
Entity Type:Individual
Prefix:MR
First Name:RICKY
Middle Name:LEE
Last Name:JENTONS
Suffix:
Gender:M
Credentials:MALLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18181 OAKWOOD BLVD
Mailing Address - Street 2:311
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-5032
Mailing Address - Country:US
Mailing Address - Phone:313-271-8170
Mailing Address - Fax:313-271-8353
Practice Address - Street 1:18181 OAKWOOD BLVD
Practice Address - Street 2:311
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-5032
Practice Address - Country:US
Practice Address - Phone:313-271-8170
Practice Address - Fax:313-271-8353
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-15
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005971103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N15280OtherAPEX BEHAVIORAL HEALTH P.L.L.C. MEDICARE GROUP PIN NO.
MI6301005971OtherLICENSE