Provider Demographics
NPI:1912696741
Name:GENUS, JACQUELYN L (LMHC)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:L
Last Name:GENUS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 ANTON WAY
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-6283
Mailing Address - Country:US
Mailing Address - Phone:931-896-6193
Mailing Address - Fax:
Practice Address - Street 1:4 AUTOMATION LN STE 100
Practice Address - Street 2:
Practice Address - City:COLONIE
Practice Address - State:NY
Practice Address - Zip Code:12205-1619
Practice Address - Country:US
Practice Address - Phone:518-919-3666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013005101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health