Provider Demographics
NPI:1659818037
Name:NAKAZAWA, JEANNE (MA, LPCC, NCC)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:NAKAZAWA
Suffix:
Gender:F
Credentials:MA, LPCC, NCC
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 802
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-0802
Mailing Address - Country:US
Mailing Address - Phone:859-985-7862
Mailing Address - Fax:
Practice Address - Street 1:292 GLADES RD STE 8
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1368
Practice Address - Country:US
Practice Address - Phone:859-985-7862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY246414101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100606150Medicaid