Provider Demographics
NPI:1265021083
Name:NYE, JENNIFER (LMSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:NYE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4510 E BANNER GATEWAY DR APT 1022
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4749
Mailing Address - Country:US
Mailing Address - Phone:708-307-5146
Mailing Address - Fax:
Practice Address - Street 1:4510 E BANNER GATEWAY DR APT 1022
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4749
Practice Address - Country:US
Practice Address - Phone:708-307-5146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-181301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical