Basic Information
| Provider Information | |||||||||
| NPI: | 1306376157 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUCLOS | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 418B W MOUNTAIN ST | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272842534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047804271 | ||||||||
| FaxNumber: | 8882616694 | ||||||||
| Practice Location | |||||||||
| Address1: | 5175 OLD CLEMMONS SCHOOL ROAD | ||||||||
| Address2: | |||||||||
| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271024020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047804271 | ||||||||
| FaxNumber: | 7047882016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2017 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 222Q00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 021564700 | 05 | FL | MEDICAID |