Provider Demographics
NPI:1417526658
Name:PROSPERE, JENNIFER CYNTHIA (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CYNTHIA
Last Name:PROSPERE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 TEAGUE DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-3752
Mailing Address - Country:US
Mailing Address - Phone:305-505-3604
Mailing Address - Fax:
Practice Address - Street 1:675 TEAGUE DR NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-3752
Practice Address - Country:US
Practice Address - Phone:305-505-3604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0074961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical