Provider Demographics
NPI:1124670500
Name:RENVILLE, JENNY (DHA, MA, LCMHCA, NCC)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:RENVILLE
Suffix:
Gender:
Credentials:DHA, MA, LCMHCA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 WAXHAW PROFESSIONAL PARK DR STE D
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-5020
Mailing Address - Country:US
Mailing Address - Phone:704-277-9009
Mailing Address - Fax:
Practice Address - Street 1:104 WAXHAW PROFESSIONAL PARK DR STE D
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-5020
Practice Address - Country:US
Practice Address - Phone:704-277-9009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16484101YP2500X, 101Y00000X, 101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health