Provider Demographics
NPI:1184260598
Name:DAVENPORT, KRISTEN NICOLE (LMSW)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NICOLE
Last Name:DAVENPORT
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 1:744 NOAH DRIVE
Mailing Address - Street 2:SUITE 113 #245
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:745 S MILLEDGE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-1252
Practice Address - Country:US
Practice Address - Phone:706-498-9560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW009099104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker