Provider Demographics
NPI:1417119561
Name:PRUITT, JENNIFER MARIE (MS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:PRUITT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1241 OBRIG AVE
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976-1430
Mailing Address - Country:US
Mailing Address - Phone:256-582-4240
Mailing Address - Fax:256-582-4161
Practice Address - Street 1:2409 HOMER CLAYTON DR
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-2207
Practice Address - Country:US
Practice Address - Phone:256-582-3203
Practice Address - Fax:256-582-3216
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51591554OtherBCBS