Healthcare Provider Details

I. General information

NPI: 1760920789
Provider Name (Legal Business Name): JENNIFER L FLACK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 14102
PHOENIX AZ
85063-4102
US

IV. Provider business mailing address

PO BOX 14102
PHOENIX AZ
85063-4102
US

V. Phone/Fax

Practice location:
  • Phone: 623-293-2232
  • Fax: 623-321-9524
Mailing address:
  • Phone: 623-293-2232
  • Fax: 623-321-9524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLCSW-17212
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-17212
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: