Provider Demographics
NPI:1164815023
Name:BETANCUR, JENNIFER (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BETANCUR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4008 LADY PALM CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-2383
Mailing Address - Country:US
Mailing Address - Phone:813-777-7407
Mailing Address - Fax:
Practice Address - Street 1:4008 LADY PALM CT
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-2383
Practice Address - Country:US
Practice Address - Phone:813-777-7407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 124751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW 12475OtherLCSW LICENSE NUMBER