Provider Demographics
NPI:1336645670
Name:PRENTISS COUNSELING AND CONSULTING PLLC
Entity Type:Organization
Organization Name:PRENTISS COUNSELING AND CONSULTING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:PRENTISS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-MHSP
Authorized Official - Phone:615-669-5605
Mailing Address - Street 1:1091 SECRETARIAT DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-3568
Mailing Address - Country:US
Mailing Address - Phone:615-669-5605
Mailing Address - Fax:
Practice Address - Street 1:5320 HICKORY HOLLOW PKWY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-3128
Practice Address - Country:US
Practice Address - Phone:615-669-5605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2904101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ014226Medicaid