Provider Demographics
NPI:1396841433
Name:KIRWIN, JENNY MAE (LCSW, LCAS, CCS)
Entity Type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:MAE
Last Name:KIRWIN
Suffix:
Gender:F
Credentials:LCSW, LCAS, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9339 CUB RUN DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-5404
Mailing Address - Country:US
Mailing Address - Phone:803-627-2401
Mailing Address - Fax:
Practice Address - Street 1:9339 CUB RUN DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-5404
Practice Address - Country:US
Practice Address - Phone:803-627-2401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC880101YA0400X
NCC0037931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002794Medicaid
NC2873433AMedicare ID - Type Unspecified