Provider Demographics
NPI:1396006722
Name:PRICE, JENNIFER SULLIVAN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:SULLIVAN
Last Name:PRICE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:208 MALLOY ST
Mailing Address - Street 2:UNIT E
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-4478
Mailing Address - Country:US
Mailing Address - Phone:919-778-5594
Mailing Address - Fax:919-778-5633
Practice Address - Street 1:208 MALLOY ST
Practice Address - Street 2:UNIT E
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-4478
Practice Address - Country:US
Practice Address - Phone:919-778-5594
Practice Address - Fax:919-778-5633
Is Sole Proprietor?:No
Enumeration Date:2012-06-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCOO77201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6009108Medicaid
NCQ39612AMedicare PIN