Provider Demographics
NPI:1912608704
Name:LAIL, JENNIFER PIERCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:PIERCE
Last Name:LAIL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7753 MIDDLE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22153-2230
Mailing Address - Country:US
Mailing Address - Phone:919-259-2168
Mailing Address - Fax:
Practice Address - Street 1:1903 ISLAND WALK WAY
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4797
Practice Address - Country:US
Practice Address - Phone:904-277-0027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY11418103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical