Provider Demographics
NPI:1902463169
Name:JERICHOW, ALEXANDRIA (MA, TLLP)
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:JERICHOW
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8505 CHESTERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SWARTZ CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:48473-1272
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:42500 HAYES RD STE 500
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-6768
Practice Address - Country:US
Practice Address - Phone:586-828-1221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI630101787103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI14473184Medicaid