Healthcare Provider Details

I. General information

NPI: 1609375534
Provider Name (Legal Business Name): JENNIFER RICCOBONO LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2018
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55951 GRATIOT AVE
CHESTERFIELD MI
48051-1221
US

IV. Provider business mailing address

50598 HELMANDALE ST
CHESTERFIELD MI
48047-3636
US

V. Phone/Fax

Practice location:
  • Phone: 586-438-0069
  • Fax:
Mailing address:
  • Phone: 586-438-0069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6361008210
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: