Provider Demographics
NPI:1386182368
Name:JACK, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JACK
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 1:729 N GREENBRIER AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24426-1319
Mailing Address - Country:US
Mailing Address - Phone:540-691-9655
Mailing Address - Fax:
Practice Address - Street 1:729 N GREENBRIER AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:VA
Practice Address - Zip Code:24426-1319
Practice Address - Country:US
Practice Address - Phone:540-691-9655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA17-6769-52485106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician