Provider Demographics
NPI:1730112913
Name:WATTENBARGER, M JENNIFER (MED, LPC)
Entity Type:Individual
Prefix:
First Name:M
Middle Name:JENNIFER
Last Name:WATTENBARGER
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 25TH AVE N
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-6103
Mailing Address - Country:US
Mailing Address - Phone:843-249-2069
Mailing Address - Fax:
Practice Address - Street 1:164 WACCAMAW MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8903
Practice Address - Country:US
Practice Address - Phone:843-347-5060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2489101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional