Provider Demographics
NPI:1902361454
Name:DALE, JENNIFER A (LPC-A)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:DALE
Suffix:
Gender:F
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 IRONCREST WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-0607
Mailing Address - Country:US
Mailing Address - Phone:803-873-1192
Mailing Address - Fax:
Practice Address - Street 1:1911 GADSDEN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-6400
Practice Address - Country:US
Practice Address - Phone:803-254-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7040101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor