Provider Demographics
NPI:1710275771
Name:ANDERSON, JENNIFER THEIS (MA, LPA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:THEIS
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MA, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7437 BRIGHT LEAF RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-7122
Mailing Address - Country:US
Mailing Address - Phone:910-524-5445
Mailing Address - Fax:
Practice Address - Street 1:2460 DELANEY AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6062
Practice Address - Country:US
Practice Address - Phone:910-792-6130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2102101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health