Provider Demographics
NPI:1659904522
Name:DOUGLAS, JENNIFER R (LPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 SASSAFRAS ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-1858
Mailing Address - Country:US
Mailing Address - Phone:814-528-0815
Mailing Address - Fax:814-528-0601
Practice Address - Street 1:1601 SASSAFRAS ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-1858
Practice Address - Country:US
Practice Address - Phone:814-528-0600
Practice Address - Fax:814-528-0601
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2021-04-28
Deactivation Date:2021-04-06
Deactivation Code:
Reactivation Date:2021-04-28
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102632671Medicaid