Provider Demographics
NPI:1740206903
Name:EMMERICH, JENNIFER LYNN (LMSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:EMMERICH
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 1:100 REDROCK RD
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86351-8656
Mailing Address - Country:US
Mailing Address - Phone:928-451-4572
Mailing Address - Fax:
Practice Address - Street 1:6446 SR 179
Practice Address - Street 2:SUITE 207-B
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86351-7990
Practice Address - Country:US
Practice Address - Phone:928-451-4572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010840371041C0700X
AZ157711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9354452OtherPRIVATE HEALTHCARE SYSTEM
MABCBSOtherBLUE CROSS BLUE SHIELD
MABCBSOtherBLUE CROSS BLUE SHIELD