Provider Demographics
NPI:1962502559
Name:THOMAS, JENNA M (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:M
Last Name:THOMAS
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 1:5830 FINCH MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:W LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-9036
Mailing Address - Country:US
Mailing Address - Phone:765-583-0267
Mailing Address - Fax:765-583-0267
Practice Address - Street 1:5830 FINCH MEADOW LN
Practice Address - Street 2:
Practice Address - City:W LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-9036
Practice Address - Country:US
Practice Address - Phone:765-583-0267
Practice Address - Fax:765-583-0267
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002496A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000232645OtherANTHEM BC/BS
IN000000232645OtherANTHEM BC/BS