Provider Demographics
NPI:1730719600
Name:SOUBA, JENNIFER LYNN (LSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:SOUBA
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6155 PLUMAS ST APT 209
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89519-6043
Mailing Address - Country:US
Mailing Address - Phone:775-515-5137
Mailing Address - Fax:
Practice Address - Street 1:3690 GRANT DR STE I
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-5360
Practice Address - Country:US
Practice Address - Phone:775-386-8755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8389-S1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1346717725Medicaid