Provider Demographics
NPI:1114429131
Name:SOUTH, JENNIFER L (PC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:SOUTH
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-1982
Mailing Address - Country:US
Mailing Address - Phone:814-362-6535
Mailing Address - Fax:
Practice Address - Street 1:110 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-1982
Practice Address - Country:US
Practice Address - Phone:814-362-6535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004917101YM0800X
PA25309452101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health