Provider Demographics
NPI:1245556752
Name:CHILDS, JEANINE KING (PHD LMHC)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:KING
Last Name:CHILDS
Suffix:
Gender:F
Credentials:PHD LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4656 W JEFFERSON BLVD STE 285
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6838
Mailing Address - Country:US
Mailing Address - Phone:260-422-9372
Mailing Address - Fax:260-422-0843
Practice Address - Street 1:4656 W JEFFERSON BLVD STE 285
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6838
Practice Address - Country:US
Practice Address - Phone:260-422-9372
Practice Address - Fax:260-422-0843
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-09
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001262A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health