Provider Demographics
NPI:1184752495
Name:CASSIDY, JENNIE MAY (PHD)
Entity type:Individual
Prefix:DR
First Name:JENNIE
Middle Name:MAY
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:280 BARCLAY DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-6572
Mailing Address - Country:US
Mailing Address - Phone:843-685-2125
Mailing Address - Fax:843-349-2898
Practice Address - Street 1:204 UNIVERSITY BLVD.
Practice Address - Street 2:COASTAL CAROLINA UNIVERSITY
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29528-6054
Practice Address - Country:US
Practice Address - Phone:843-349-2305
Practice Address - Fax:843-349-2898
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1042103TC1900X, 103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy