Provider Demographics
NPI:1568529626
Name:JENNETTE, A. DOUGLAS (MSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:A.
Middle Name:DOUGLAS
Last Name:JENNETTE
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4816 SIX FORKS RD STE 104
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-5250
Mailing Address - Country:US
Mailing Address - Phone:919-781-6393
Mailing Address - Fax:919-781-1589
Practice Address - Street 1:4816 SIX FORKS RD STE 104
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-5250
Practice Address - Country:US
Practice Address - Phone:919-781-6393
Practice Address - Fax:919-781-1589
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC-0000511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2879534Medicare PIN