Provider Demographics
NPI:1619594173
Name:KIRSTEN, JEAN (LCSW)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:KIRSTEN
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 1:549 HC/BAACH
Mailing Address - Street 2:UNIT 15245
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96271
Mailing Address - Country:KR
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:549 HC/BAACH
Practice Address - Street 2:UNIT 15245
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96271
Practice Address - Country:KR
Practice Address - Phone:315-737-5171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC013118104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TRICAREOtherTRICARE