Provider Demographics
NPI:1346988029
Name:CASSITY, JENNIFER DAWN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:CASSITY
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 1:101 N RIDGE RD STE 6
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-3367
Mailing Address - Country:US
Mailing Address - Phone:316-409-0565
Mailing Address - Fax:
Practice Address - Street 1:101 N RIDGE RD STE 6
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-3367
Practice Address - Country:US
Practice Address - Phone:316-409-0565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04056-T101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional