Healthcare Provider Details

I. General information

NPI: 1386645331
Provider Name (Legal Business Name): JENNIFER NOONAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER SMITH LCSW

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 BROADWAY
GARY IN
46408-4605
US

IV. Provider business mailing address

PO BOX 746715
ATLANTA GA
30374-6715
US

V. Phone/Fax

Practice location:
  • Phone: 219-237-5170
  • Fax: 219-321-1931
Mailing address:
  • Phone: 773-352-1515
  • Fax: 312-929-0373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number260380
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9290
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34004751A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: