Provider Demographics
NPI:1174158976
Name:WALLACE, JENNIFER DAWN (LPCC/S)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPCC/S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 BEVINS LN STE A
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-6145
Mailing Address - Country:US
Mailing Address - Phone:859-951-9777
Mailing Address - Fax:859-951-9779
Practice Address - Street 1:204 BEVINS LN STE A
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-6145
Practice Address - Country:US
Practice Address - Phone:859-951-9777
Practice Address - Fax:859-951-9779
Is Sole Proprietor?:No
Enumeration Date:2020-03-12
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104157101YP2500X
KY104157101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor