Provider Demographics
NPI:1821615980
Name:GUEVARA, JENNIFER LEE (LCSW-A)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:GUEVARA
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 N 16TH ST STE 316
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-1266
Mailing Address - Country:US
Mailing Address - Phone:602-636-4409
Mailing Address - Fax:
Practice Address - Street 1:215B MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6333
Practice Address - Country:US
Practice Address - Phone:252-747-7824
Practice Address - Fax:910-577-0383
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-26769101YA0400X
NCP0147551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)