Provider Demographics
NPI:1184450769
Name:BOSTON, JENNIFER HEATH (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HEATH
Last Name:BOSTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:HEATH
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:419 DIXIE DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-1556
Mailing Address - Country:US
Mailing Address - Phone:757-667-1563
Mailing Address - Fax:
Practice Address - Street 1:419 DIXIE DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-1556
Practice Address - Country:US
Practice Address - Phone:757-667-1563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
VA09040172361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical