Provider Demographics
NPI:1134902869
Name:FRY, JENNIFER LYNN (LMSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:FRY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 RAINBOW BLVD
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64024-1182
Mailing Address - Country:US
Mailing Address - Phone:816-629-8821
Mailing Address - Fax:816-629-2701
Practice Address - Street 1:1700 RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:EXCELSIOR SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64024-1182
Practice Address - Country:US
Practice Address - Phone:816-629-8821
Practice Address - Fax:816-629-2701
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010020809101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health