Provider Demographics
NPI:1013740240
Name:CLEMONS, JESSICA DAWN (MA, TLLP)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:DAWN
Last Name:CLEMONS
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6509 CHEYNE CT
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3179
Mailing Address - Country:US
Mailing Address - Phone:248-661-5792
Mailing Address - Fax:
Practice Address - Street 1:1 PARKLANE BLVD STE 200E
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2400
Practice Address - Country:US
Practice Address - Phone:313-846-2606
Practice Address - Fax:313-846-2657
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362010007103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist