Provider Demographics
NPI:1144474289
Name:CUNNINGHAM, JENESSIA L (LCSW)
Entity type:Individual
Prefix:
First Name:JENESSIA
Middle Name:L
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 ISLAND PARK BLVD APT 719
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4767
Mailing Address - Country:US
Mailing Address - Phone:318-347-6245
Mailing Address - Fax:
Practice Address - Street 1:510 E. STONER AVENUE
Practice Address - Street 2:OVERTON BROOKS VA MEDICAL CENTER
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4295
Practice Address - Country:US
Practice Address - Phone:318-990-4704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-14
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8962104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker