Provider Demographics
NPI:1528793684
Name:MANNINO, JENNIFER (LPC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MANNINO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 N RIVER ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3800
Mailing Address - Country:US
Mailing Address - Phone:810-309-9355
Mailing Address - Fax:810-750-1152
Practice Address - Street 1:127 N RIVER ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3800
Practice Address - Country:US
Practice Address - Phone:810-309-9355
Practice Address - Fax:810-750-1152
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401222784101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401222784OtherLICENSED PROFESSIONAL COUNSELOR
MI6401222784Medicaid