Provider Demographics
NPI:1386192177
Name:CARLSON, JENNIFER K (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:K
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:K
Other - Last Name:ANDERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1920 BRIARCLIFF RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-4010
Mailing Address - Country:US
Mailing Address - Phone:404-785-4927
Mailing Address - Fax:
Practice Address - Street 1:1920 BRIARCLIFF RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329
Practice Address - Country:US
Practice Address - Phone:404-785-4927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.009836103TC0700X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst