Provider Demographics
NPI:1184766800
Name:WHITCOMB, JENNELLE RACHEL (LCSW-R)
Entity type:Individual
Prefix:MRS
First Name:JENNELLE
Middle Name:RACHEL
Last Name:WHITCOMB
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:JENNELLE
Other - Middle Name:RACHEL
Other - Last Name:BLOOMBERG-WHITCOMB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2128 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14207-1910
Mailing Address - Country:US
Mailing Address - Phone:716-874-4500
Mailing Address - Fax:716-874-3195
Practice Address - Street 1:2128 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14207-1910
Practice Address - Country:US
Practice Address - Phone:716-874-4500
Practice Address - Fax:716-874-3195
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0358141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01465154Medicaid
3300881570OtherCLIA