Provider Demographics
NPI:1538597331
Name:ETHRIDGE, JENNIFER MAJORS (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MAJORS
Last Name:ETHRIDGE
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 1:321 EAST BLVD APT 3
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4815
Mailing Address - Country:US
Mailing Address - Phone:704-577-6770
Mailing Address - Fax:
Practice Address - Street 1:321 EAST BLVD APT 3
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4815
Practice Address - Country:US
Practice Address - Phone:980-689-0778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-15
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0098791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC12634502Medicaid