MEDICARE: JENNIFER STATEN, LCSW, LLC

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1629669981
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JENNIFER STATEN, LCSW, LLC

Provider Business Mailing Address
First Line	:	PO BOX 146
Second Line	:
City	:	SULPHUR SPRINGS
State	:	TX
Zip	:	75483-0146
Country	:	US
Telephone Number	:	903-885-2776
Fax Number	:

Provider Business Practice Location Address
First Line	:	2121 MAIN ST
Second Line	:
City	:	SULPHUR SPRINGS
State	:	TX
Zip	:	75482-3616
Country	:	US
Telephone Number	:	903-885-2776
Fax Number	:

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	JENNIFER N STATEN
Credential	:	LCSW
Telephone Number	:	903-577-6263

Provider Enumeration Date	:	01/29/2021
Last Update Date	:	03/11/2023

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