Provider Demographics
NPI:1255979431
Name:VIRDEN, JEANETTE LOUISE (LMSW)
Entity type:Individual
Prefix:MS
First Name:JEANETTE
Middle Name:LOUISE
Last Name:VIRDEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1863 HOUGHTON DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-2939
Mailing Address - Country:US
Mailing Address - Phone:630-361-4040
Mailing Address - Fax:
Practice Address - Street 1:200 E 5TH NORTH STREET
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483
Practice Address - Country:US
Practice Address - Phone:843-647-2346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13392101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health