Provider Demographics
NPI:1073862017
Name:CONNOLLY, JENNIFER C (PLCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:PLCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 FAIRHILL DRIVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3215
Mailing Address - Country:US
Mailing Address - Phone:919-256-0824
Mailing Address - Fax:919-256-0833
Practice Address - Street 1:725 N. HIGHLAND AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-4206
Practice Address - Country:US
Practice Address - Phone:336-607-8501
Practice Address - Fax:336-725-4030
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP006709101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor