Provider Demographics
NPI:1699212670
Name:DAVIS, JENNY
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82443-2634
Mailing Address - Country:US
Mailing Address - Phone:307-864-3138
Mailing Address - Fax:307-864-3139
Practice Address - Street 1:121 S 4TH ST
Practice Address - Street 2:
Practice Address - City:THERMOPOLIS
Practice Address - State:WY
Practice Address - Zip Code:82443-2634
Practice Address - Country:US
Practice Address - Phone:307-864-3138
Practice Address - Fax:307-864-3139
Is Sole Proprietor?:No
Enumeration Date:2017-01-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-983101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor