Provider Demographics
NPI:1801192778
Name:EVANS, JENNIFER M (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:M
Last Name:EVANS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:DESFORGES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:284 EXECUTIVE PARK DR.
Mailing Address - Street 2:STE 100
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1833
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:847 W LAKE DR
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-2157
Practice Address - Country:US
Practice Address - Phone:336-783-6919
Practice Address - Fax:336-783-6923
Is Sole Proprietor?:No
Enumeration Date:2011-02-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0089541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1326440066OtherUNITED BEHAVIORAL HEALTH
NC19LHLOtherBCBS
NC601121-053OtherMAGELLAN
NC1326440066Medicaid
NC1326440066OtherHUMANA
NCQ48420AOtherMEDICARE