1477194595 NPI number — MRS. JESSICA SHANNON TRIPP LMSW

Table of content: MRS. JESSICA SHANNON TRIPP LMSW (NPI 1477194595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477194595 NPI number — MRS. JESSICA SHANNON TRIPP LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRIPP
Provider First Name:
JESSICA
Provider Middle Name:
SHANNON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RITCHHART
Provider Other First Name:
JESS
Provider Other Middle Name:
SHANNON
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477194595
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6549 TOWN CENTER DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARKSTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48346-4824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-620-6400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26522 VAN DYKE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTER LINE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48015-1221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-759-4400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801086858 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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