Provider Demographics
NPI:1134481062
Name:FORD, JENNIFER LAUREN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LAUREN
Last Name:FORD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:367-160-2383
Mailing Address - Fax:
Practice Address - Street 1:3325 SILAS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3013
Practice Address - Country:US
Practice Address - Phone:336-713-4500
Practice Address - Fax:336-713-4501
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05664700133N00000X
NCC0091351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No133N00000XDietary & Nutritional Service ProvidersNutritionist