Healthcare Provider Details

I. General information

NPI: 1437077138
Provider Name (Legal Business Name): MYRANDA JENNINGS LPC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 W GRAND RIVER AVE STE A
OKEMOS MI
48864-1604
US

IV. Provider business mailing address

15117 CHATHAM ST
DETROIT MI
48223-1889
US

V. Phone/Fax

Practice location:
  • Phone: 586-806-9726
  • Fax: 313-216-1811
Mailing address:
  • Phone: 586-806-9726
  • Fax: 313-216-1811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MYRANDA ELLINGSEN
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: LPC
Phone: 586-806-9726