Provider Demographics
NPI:1023109337
Name:UPCHURCH, JENNIFER (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:UPCHURCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:7741 MARKET ST
Mailing Address - Street 2:STE A
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-9444
Mailing Address - Country:US
Mailing Address - Phone:910-228-8522
Mailing Address - Fax:910-498-0220
Practice Address - Street 1:7741 MARKET ST
Practice Address - Street 2:STE A
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-9444
Practice Address - Country:US
Practice Address - Phone:910-228-8522
Practice Address - Fax:910-498-0220
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0044811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003480Medicaid
NC6003480Medicaid