Provider Demographics
NPI:1831808609
Name:PENNYMON, JACOBI
Entity type:Individual
Prefix:
First Name:JACOBI
Middle Name:
Last Name:PENNYMON
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 1:23434 LEGACY BLVD
Mailing Address - Street 2:
Mailing Address - City:MACOMB TOWNSHIP, MICHIGAN, UNITED STATES
Mailing Address - State:MI
Mailing Address - Zip Code:48042
Mailing Address - Country:US
Mailing Address - Phone:586-935-2046
Mailing Address - Fax:
Practice Address - Street 1:23434 LEGACY BLVD
Practice Address - Street 2:
Practice Address - City:MACOMB TOWNSHIP, MICHIGAN, UNITED S
Practice Address - State:MI
Practice Address - Zip Code:48042-4804
Practice Address - Country:US
Practice Address - Phone:586-935-2046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician