MEDICARE: MRS. JENNA BONNELL CANTERBURY LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	14933	FL
2	1041C0700X	Clinical Social Worker	14933	FL

General Provider Information

NPI Number	:	1336790633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNA BONNELL CANTERBURY LCSW

Provider Business Mailing Address
First Line	:	926 CLEVELAND ST APT 4208
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29601-4651
Country	:	US
Telephone Number	:	229-560-6009
Fax Number	:

Provider Business Practice Location Address
First Line	:	926 CLEVELAND ST APT 4208
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29601-4651
Country	:	US
Telephone Number	:	229-560-6009
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2019
Last Update Date	:	04/16/2023

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