Provider Demographics
NPI:1699019992
Name:CONLEY, JENNIFER REBECCA (LISW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:REBECCA
Last Name:CONLEY
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 CARLTON DAVIDSON LN
Mailing Address - Street 2:
Mailing Address - City:COAL GROVE
Mailing Address - State:OH
Mailing Address - Zip Code:45638-2924
Mailing Address - Country:US
Mailing Address - Phone:740-354-7702
Mailing Address - Fax:740-353-1662
Practice Address - Street 1:225 CARLTON DAVIDSON LN
Practice Address - Street 2:
Practice Address - City:COAL GROVE
Practice Address - State:OH
Practice Address - Zip Code:45638-2924
Practice Address - Country:US
Practice Address - Phone:740-354-7702
Practice Address - Fax:740-353-1662
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36771041C0700X
OHI.13022481041C0700X
WVDP009442651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005355002Medicaid
KY30610026Medicaid
WV0005355002Medicaid