Provider Demographics
NPI:1326618588
Name:THAKUR, JENNIFER EVON
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:EVON
Last Name:THAKUR
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 1:364 RALEIGH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-9047
Mailing Address - Country:US
Mailing Address - Phone:919-647-4600
Mailing Address - Fax:
Practice Address - Street 1:1143 EXECUTIVE CIR STE A
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-4571
Practice Address - Country:US
Practice Address - Phone:919-391-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16686101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health