Provider Demographics
NPI:1073892816
Name:KNOWLTON, JENNIFER SUZANNE (LPC, LAT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:SUZANNE
Last Name:KNOWLTON
Suffix:
Gender:F
Credentials:LPC, LAT
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:SUZANNE
Other - Last Name:SCHMIDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 976
Mailing Address - Street 2:
Mailing Address - City:THAYNE
Mailing Address - State:WY
Mailing Address - Zip Code:83127-0976
Mailing Address - Country:US
Mailing Address - Phone:307-264-5782
Mailing Address - Fax:307-883-5782
Practice Address - Street 1:383 N MAIN ST, 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:THAYNE
Practice Address - State:WY
Practice Address - Zip Code:83127
Practice Address - Country:US
Practice Address - Phone:307-264-5782
Practice Address - Fax:307-883-5782
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-10
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
WYPAT-058101YA0400X
WY172V00000X
WYLPC 1527101YP2500X
WYPPC-823101YP2500X
WYLAT-351101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No172V00000XOther Service ProvidersCommunity Health Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)