Provider Demographics
NPI:1902273410
Name:KING, JENNIFER B (MED, LPC, CSC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:B
Last Name:KING
Suffix:
Gender:F
Credentials:MED, LPC, CSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3581 GA HIGHWAY 300
Mailing Address - Street 2:
Mailing Address - City:OAKFIELD
Mailing Address - State:GA
Mailing Address - Zip Code:31772-1826
Mailing Address - Country:US
Mailing Address - Phone:229-869-2963
Mailing Address - Fax:
Practice Address - Street 1:3581 GA HIGHWAY 300
Practice Address - Street 2:
Practice Address - City:OAKFIELD
Practice Address - State:GA
Practice Address - Zip Code:31772-1826
Practice Address - Country:US
Practice Address - Phone:229-869-2963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008398101YM0800X
GA394268101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool