Provider Demographics
NPI:1962016204
Name:FERGUSON, JENNA TYLER
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:TYLER
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 BERKELEY ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-3507
Mailing Address - Country:US
Mailing Address - Phone:704-516-4601
Mailing Address - Fax:
Practice Address - Street 1:3622 LYCKAN PKWY STE 3002
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2572
Practice Address - Country:US
Practice Address - Phone:919-602-6766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0128961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical