Provider Demographics
NPI:1790964054
Name:LIGHT, JENNIFER ELAINE (LMSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELAINE
Last Name:LIGHT
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 1:555 N WOODLAWN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3646
Mailing Address - Country:US
Mailing Address - Phone:316-685-1821
Mailing Address - Fax:
Practice Address - Street 1:2400 S 48TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-6683
Practice Address - Country:US
Practice Address - Phone:479-750-2020
Practice Address - Fax:479-872-2441
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-02
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS46381041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool