Provider Demographics
NPI:1043569254
Name:CIANCIOLO, JENNIFER DEHAVEN (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DEHAVEN
Last Name:CIANCIOLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 SMOKETREE CT # 301
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-7481
Mailing Address - Country:US
Mailing Address - Phone:704-281-1114
Mailing Address - Fax:
Practice Address - Street 1:7810 BALLANTYNE COMMONS PKWY STE 228
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3416
Practice Address - Country:US
Practice Address - Phone:704-727-8788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-04
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0092411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical