Provider Demographics
NPI:1598041832
Name:FLACK, JENNIFER LYDIA (MED, NCC, LPC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYDIA
Last Name:FLACK
Suffix:
Gender:F
Credentials:MED, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTTDALE
Mailing Address - State:PA
Mailing Address - Zip Code:15683-2102
Mailing Address - Country:US
Mailing Address - Phone:724-953-9733
Mailing Address - Fax:
Practice Address - Street 1:209 S MAPLE AVE
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-3216
Practice Address - Country:US
Practice Address - Phone:724-420-5038
Practice Address - Fax:724-420-5863
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC005970101YP2500X
PA101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool