Provider Demographics
NPI:1306376157
Name:DUCLOS, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DUCLOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418B W MOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-2534
Mailing Address - Country:US
Mailing Address - Phone:704-780-4271
Mailing Address - Fax:888-261-6694
Practice Address - Street 1:5175 OLD CLEMMONS SCHOOL ROAD
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27102-4020
Practice Address - Country:US
Practice Address - Phone:704-780-4271
Practice Address - Fax:704-788-2016
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021564700Medicaid