Provider Demographics
NPI:1396004735
Name:WOODALL, JENNIFER LYNN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:WOODALL
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 1:5426 VEGAS DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-2403
Mailing Address - Country:US
Mailing Address - Phone:702-604-7767
Mailing Address - Fax:702-485-1107
Practice Address - Street 1:5426 VEGAS DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-2403
Practice Address - Country:US
Practice Address - Phone:702-604-7767
Practice Address - Fax:702-485-1107
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-04
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8959-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical