Provider Demographics
NPI:1104839687
Name:GENNERO, JACELYN MARIE (LMSW)
Entity type:Individual
Prefix:
First Name:JACELYN
Middle Name:MARIE
Last Name:GENNERO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2387 E WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-1955
Mailing Address - Country:US
Mailing Address - Phone:248-475-6300
Mailing Address - Fax:248-475-6302
Practice Address - Street 1:2387 E WALTON BLVD
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-1955
Practice Address - Country:US
Practice Address - Phone:248-475-6300
Practice Address - Fax:248-475-6302
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010856031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical