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NPI Code Detail

MEDICARE: JACELYN MARIE GENNERO LMSW

MEDICARE: JACELYN MARIE GENNERO LMSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker6801085603MI

General Provider Information

NPI Number : 1104839687
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACELYN MARIE GENNERO LMSW
Provider Business Mailing Address
First Line : 2387 E WALTON BLVD
Second Line :
City : AUBURN HILLS
State : MI
Zip : 48326-1955
Country : US
Telephone Number : 248-475-6300
Fax Number : 248-475-6302
Provider Business Practice Location Address
First Line : 2387 E WALTON BLVD
Second Line :
City : AUBURN HILLS
State : MI
Zip : 48326-1955
Country : US
Telephone Number : 248-475-6300
Fax Number : 248-475-6302
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/14/2006
Last Update Date : 11/29/2010

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