Provider Demographics
NPI:1619339108
Name:MOSTAFA, JENNIFER (LPC, LCPC, NCC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MOSTAFA
Suffix:
Gender:F
Credentials:LPC, LCPC, NCC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ELAINE
Other - Last Name:MOSTAFA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66027-1303
Mailing Address - Country:US
Mailing Address - Phone:913-683-8751
Mailing Address - Fax:
Practice Address - Street 1:601 GRANT AVE
Practice Address - Street 2:
Practice Address - City:FORT LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027-1303
Practice Address - Country:US
Practice Address - Phone:913-683-8751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLGPC00113101Y00000X
DCPRC15103101YP2500X
KSLCPC03030101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor