Provider Demographics
NPI:1619019882
Name:PAGE, JENNIFER LEE (LMFT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:PAGE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1794
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42702-1794
Mailing Address - Country:US
Mailing Address - Phone:270-300-4411
Mailing Address - Fax:
Practice Address - Street 1:331 OLD CARDINAL DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2781
Practice Address - Country:US
Practice Address - Phone:270-300-4411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY887106H00000X
KY2012-018106H00000X
KY105305106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30605018Medicaid