Provider Demographics
NPI:1174099790
Name:STACK, JENNA (LCMHC-A, LCAS-A)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:STACK
Suffix:
Gender:F
Credentials:LCMHC-A, LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2806 REYNOLDA RD STE 257
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3102
Mailing Address - Country:US
Mailing Address - Phone:336-223-6700
Mailing Address - Fax:
Practice Address - Street 1:2806 REYNOLDA RD STE 257
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3102
Practice Address - Country:US
Practice Address - Phone:336-223-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-24745101YA0400X
NCA14431101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)