Provider Demographics
NPI:1346550522
Name:MEDINA, JENNIFER KATHRYN (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KATHRYN
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:KATHRYN
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 NAVAHO DR
Mailing Address - Street 2:SUITE 114
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7319
Mailing Address - Country:US
Mailing Address - Phone:919-297-2357
Mailing Address - Fax:919-890-3866
Practice Address - Street 1:2108 UMSTEAD DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603
Practice Address - Country:US
Practice Address - Phone:919-445-0837
Practice Address - Fax:919-733-9441
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0070201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical