Provider Demographics
NPI:1760920789
Name:FLACK, JENNIFER L (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:FLACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13321 W INDIAN SCHOOL RD
Mailing Address - Street 2:STE A107
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-4339
Mailing Address - Country:US
Mailing Address - Phone:602-550-7844
Mailing Address - Fax:
Practice Address - Street 1:13321 W INDIAN SCHOOL RD
Practice Address - Street 2:STE A107
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-4339
Practice Address - Country:US
Practice Address - Phone:480-565-3035
Practice Address - Fax:480-500-3902
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-17212104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ427136Medicaid