Provider Demographics
NPI:1245240811
Name:DELOACH, JENNIFER L (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:DELOACH
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 1:8609 GIANT CITY RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-6238
Mailing Address - Country:US
Mailing Address - Phone:618-351-8226
Mailing Address - Fax:
Practice Address - Street 1:8609 GIANT CITY RD
Practice Address - Street 2:SUITE F
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62902-6238
Practice Address - Country:US
Practice Address - Phone:618-351-8226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW11711041C0700X
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical