Provider Demographics
NPI:1609375534
Name:RICCOBONO, JENNIFER (TLLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RICCOBONO
Suffix:
Gender:
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50598 HELMANDALE ST
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-3636
Mailing Address - Country:US
Mailing Address - Phone:586-438-0069
Mailing Address - Fax:
Practice Address - Street 1:6770 DIXIE HWY STE 314
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-5114
Practice Address - Country:US
Practice Address - Phone:248-762-5820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-06
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009367103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical