Provider Demographics
NPI:1780699371
Name:STEPHENS, JENNIFER ANN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:998 BROOKS INDUSTRIAL RD
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-8154
Mailing Address - Country:US
Mailing Address - Phone:502-633-1315
Mailing Address - Fax:502-633-1316
Practice Address - Street 1:998 BROOKS INDUSTRIAL RD
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-8154
Practice Address - Country:US
Practice Address - Phone:502-633-1315
Practice Address - Fax:502-633-1316
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1519101YP2500X
KY163696103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30606099Medicaid