Healthcare Provider Details

I. General information

NPI: 1588951578
Provider Name (Legal Business Name): JENNIFER FARNSWORTH KUCK LMFT, LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 08/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 NORTHRIDGE RD SUITE 310
ATLANTA GA
30350-3207
US

IV. Provider business mailing address

365 NORTHRIDGE RD SUITE 310
ATLANTA GA
30350-3207
US

V. Phone/Fax

Practice location:
  • Phone: 770-771-6900
  • Fax: 770-771-6901
Mailing address:
  • Phone: 770-771-6900
  • Fax: 770-771-6901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC006905
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT001323
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: