Provider Demographics
NPI:1902639693
Name:KELLENBERGER, JACOB LEE (MS, TLLP)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:LEE
Last Name:KELLENBERGER
Suffix:
Gender:M
Credentials:MS, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 E GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-2322
Mailing Address - Country:US
Mailing Address - Phone:989-510-7626
Mailing Address - Fax:
Practice Address - Street 1:323 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-2322
Practice Address - Country:US
Practice Address - Phone:909-510-7626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009950103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical