Provider Demographics
NPI:1891199006
Name:WATERBURY, JENNA RENEE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:RENEE
Last Name:WATERBURY
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 1:2940 16TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34117-5541
Mailing Address - Country:US
Mailing Address - Phone:517-403-3442
Mailing Address - Fax:
Practice Address - Street 1:11983 TAMIAMI TRL N STE 152
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-1609
Practice Address - Country:US
Practice Address - Phone:517-403-3442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010858611041C0700X
FLSW 120791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical