Healthcare Provider Details

I. General information

NPI: 1225245483
Provider Name (Legal Business Name): JENEVIEVE LYNN WARDELL LPC-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2375 MEMPHIS ST
HERNANDO MS
38632-1756
US

IV. Provider business mailing address

657 DOE CREEK TRL N
HERNANDO MS
38632-5018
US

V. Phone/Fax

Practice location:
  • Phone: 662-506-3836
  • Fax: 662-200-5976
Mailing address:
  • Phone: 704-231-4215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12683
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2757
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: