Provider Demographics
NPI:1639554058
Name:MINNICKS, JENNIFER (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MINNICKS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 W PARK SQ NE STE D
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-2294
Mailing Address - Country:US
Mailing Address - Phone:912-690-4911
Mailing Address - Fax:
Practice Address - Street 1:13 W PARK SQ NE STE D
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-2294
Practice Address - Country:US
Practice Address - Phone:912-690-4911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0055591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical