Provider Demographics
NPI:1518194620
Name:SAMARDAK, JENNIFER A (LISW-S)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:SAMARDAK
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3408 MAPLE TIMBER DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-5452
Mailing Address - Country:US
Mailing Address - Phone:330-671-4374
Mailing Address - Fax:
Practice Address - Street 1:3408 MAPLE TIMBER DR
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-5452
Practice Address - Country:US
Practice Address - Phone:330-671-4374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0700085.SUPV101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor