Healthcare Provider Details

I. General information

NPI: 1194027433
Provider Name (Legal Business Name): JENNIFER LYNN MCCUTCHEON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2010
Last Update Date: 11/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4118 MILLER ST
BETHANY MO
64424-7169
US

IV. Provider business mailing address

2205 OAKLAND AVE
BETHANY MO
64424-1348
US

V. Phone/Fax

Practice location:
  • Phone: 660-537-9030
  • Fax:
Mailing address:
  • Phone: 660-537-9030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2010038676
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: