=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083388128
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JENELLE K. LEIB, MA LPC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2021
-----------------------------------------------------
Last Update Date | 08/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 E BROADWAY ST STE 4A
-----------------------------------------------------
City | MOUNT PLEASANT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48858-2659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-572-0004
-----------------------------------------------------
Fax | 989-702-2266
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 306 E BROADWAY ST STE 4A
-----------------------------------------------------
City | MOUNT PLEASANT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48858-2659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-572-0004
-----------------------------------------------------
Fax | 989-702-2266
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LPC
-----------------------------------------------------
Name | JENELLE K LEIB
-----------------------------------------------------
Credential | MA LPC
-----------------------------------------------------
Telephone | 989-572-0004
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------