Provider Demographics
NPI:1205498607
Name:MCGLYNN, JENNIFER KRISTINE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KRISTINE
Last Name:MCGLYNN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:KRISTINE
Other - Last Name:MCGLYNN PATERNO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2428 W. REYNODS AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531
Mailing Address - Country:US
Mailing Address - Phone:360-330-9044
Mailing Address - Fax:
Practice Address - Street 1:2428 W. REYNODS AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531
Practice Address - Country:US
Practice Address - Phone:360-330-9044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60963218101YM0800X
WALW61491945104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker