Provider Demographics
NPI:1447569884
Name:ENEVOLDSEN, JENNIFER J (LMSW, LCSW-P)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:J
Last Name:ENEVOLDSEN
Suffix:
Gender:F
Credentials:LMSW, LCSW-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 FAIRHILL DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3215
Mailing Address - Country:US
Mailing Address - Phone:252-438-2581
Mailing Address - Fax:252-431-9145
Practice Address - Street 1:309 WYCHE ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-4246
Practice Address - Country:US
Practice Address - Phone:252-438-2581
Practice Address - Fax:252-431-9145
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC95341041C0700X
NCP0069291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC457633Medicaid