Provider Demographics
NPI:1255545398
Name:KERENICK, JOLIE GLASSMAN (LCSW)
Entity type:Individual
Prefix:
First Name:JOLIE
Middle Name:GLASSMAN
Last Name:KERENICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 LINDEN CV
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-4403
Mailing Address - Country:US
Mailing Address - Phone:601-709-1253
Mailing Address - Fax:
Practice Address - Street 1:1900 N WEST ST
Practice Address - Street 2:SUITE D
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1033
Practice Address - Country:US
Practice Address - Phone:601-709-1253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC58731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08138320Medicaid