Provider Demographics
NPI:1952602468
Name:STURDIVAN, JENIFER DAWN (MA, LPC)
Entity Type:Individual
Prefix:MISS
First Name:JENIFER
Middle Name:DAWN
Last Name:STURDIVAN
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 802843
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-2843
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:3800 S NATIONAL AVE STE 770
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5283
Practice Address - Country:US
Practice Address - Phone:417-269-6891
Practice Address - Fax:417-269-5595
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-15
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003031833101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
12602676OtherCAQH