Provider Demographics
NPI:1639285398
Name:BLICKENSTAFF, JENNIFER LYNN (LCP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:BLICKENSTAFF
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 W CENTRAL AVE
Mailing Address - Street 2:SUITE H
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002-9687
Mailing Address - Country:US
Mailing Address - Phone:316-733-9469
Mailing Address - Fax:316-733-8421
Practice Address - Street 1:310 W CENTRAL AVE
Practice Address - Street 2:SUITE H
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002-9687
Practice Address - Country:US
Practice Address - Phone:316-733-9469
Practice Address - Fax:316-733-8421
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS280103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral