Provider Demographics
NPI:1003597766
Name:EVANS, JENNIFER MICHELE (MFT ASSOCIATE)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELE
Last Name:EVANS
Suffix:
Gender:F
Credentials:MFT ASSOCIATE
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MICHELE
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JENNIFER BRUCKERT
Mailing Address - Street 1:121 S PUBLIC SQ
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:42743-1532
Mailing Address - Country:US
Mailing Address - Phone:270-206-2601
Mailing Address - Fax:
Practice Address - Street 1:121 S PUBLIC SQ
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:KY
Practice Address - Zip Code:42743-1532
Practice Address - Country:US
Practice Address - Phone:270-206-2601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY266154106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist