Provider Demographics
NPI:1801843255
Name:WHITEHEAD, JEANNE K (LCSW, LMFT)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:K
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6327 CROFTON DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-8730
Mailing Address - Country:US
Mailing Address - Phone:260-485-0121
Mailing Address - Fax:
Practice Address - Street 1:4656 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6857
Practice Address - Country:US
Practice Address - Phone:260-432-4346
Practice Address - Fax:260-432-4860
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003073A1041C0700X
IN35000690A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist