1093955221 NPI number — JENNIFER K KENDRICK LCSW

Table of content: JENNIFER K KENDRICK LCSW (NPI 1093955221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093955221 NPI number — JENNIFER K KENDRICK LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENDRICK
Provider First Name:
JENNIFER
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILDER
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
K
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093955221
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 234
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOONEVILLE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38829-0234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-219-3344
Provider Business Mailing Address Fax Number:
855-610-2250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 UNION BELLE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALTILLO
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38866-8107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-869-3042
Provider Business Practice Location Address Fax Number:
662-869-3405
Provider Enumeration Date:
02/27/2009

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:  C5777 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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