Provider Demographics
NPI:1063843613
Name:MINICHAN, JENNIFER REED (MS, EDS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:REED
Last Name:MINICHAN
Suffix:
Gender:F
Credentials:MS, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 HERNDON DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-8877
Mailing Address - Country:US
Mailing Address - Phone:803-641-2624
Mailing Address - Fax:
Practice Address - Street 1:1000 BROOKHAVEN DR
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-2109
Practice Address - Country:US
Practice Address - Phone:803-641-2624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1553101YP2500X
SC162252101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool