Provider Demographics
NPI:1720550288
Name:WHITEHEAD, JENNIFER LYN (LMSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYN
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 W FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-5611
Mailing Address - Country:US
Mailing Address - Phone:423-439-7371
Mailing Address - Fax:
Practice Address - Street 1:202 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5611
Practice Address - Country:US
Practice Address - Phone:423-439-7371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW0000010776104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker