Basic Information
| Provider Information | |||||||||
| NPI: | 1619143211 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JENNIFER CLEMONS, LCSW, INC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1088 BROWN AVE | ||||||||
| Address2: | |||||||||
| City: | WAYNESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287861918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284005488 | ||||||||
| FaxNumber: | 8284568903 | ||||||||
| Practice Location | |||||||||
| Address1: | 1088 BROWN AVE | ||||||||
| Address2: | |||||||||
| City: | WAYNESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287861918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284005488 | ||||||||
| FaxNumber: | 8284568903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2008 | ||||||||
| LastUpdateDate: | 05/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | CLEMONS | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8284005488 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | C005286 | NC | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 143CU | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 6106342 | 05 | NC | MEDICAID |