Basic Information
| Provider Information | |||||||||
| NPI: | 1699019992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONLEY | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | REBECCA | ||||||||
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| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 CARLTON DAVIDSON LN | ||||||||
| Address2: | |||||||||
| City: | COAL GROVE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456382924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403547702 | ||||||||
| FaxNumber: | 7403531662 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 CARLTON DAVIDSON LN | ||||||||
| Address2: | |||||||||
| City: | COAL GROVE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456382924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403547702 | ||||||||
| FaxNumber: | 7403531662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2012 | ||||||||
| LastUpdateDate: | 10/05/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 3677 | KY | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | I.1302248 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | DP00944265 | WV | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0005355002 | 05 | WV | MEDICAID | 30610026 | 05 | KY | MEDICAID |