Provider Demographics
NPI:1275023111
Name:WALSH, JENNIFER LEE (LCMHC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LEE
Last Name:WALSH
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 GUM BRANCH RD STE O
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-6269
Mailing Address - Country:US
Mailing Address - Phone:910-545-2719
Mailing Address - Fax:
Practice Address - Street 1:824 GUM BRANCH RD STE O
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-6269
Practice Address - Country:US
Practice Address - Phone:910-545-2719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13132101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health