Provider Demographics
NPI:1922200765
Name:FANIEL, JENNIFER ANNE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANNE
Last Name:FANIEL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3080 HENDERSON DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-5246
Mailing Address - Country:US
Mailing Address - Phone:910-938-9833
Mailing Address - Fax:910-938-9835
Practice Address - Street 1:3080 HENDERSON DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5246
Practice Address - Country:US
Practice Address - Phone:910-938-9833
Practice Address - Fax:910-938-9835
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6570101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103584Medicaid