Healthcare Provider Details

I. General information

NPI: 1144933680
Provider Name (Legal Business Name): JENNIFER WHITEHEAD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2022
Last Update Date: 12/29/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 ROXBURY ST
KEENE NH
03431-3257
US

IV. Provider business mailing address

196 SOUTH LINCOLN STREET KEENE
KEENE NH
03431
US

V. Phone/Fax

Practice location:
  • Phone: 603-620-3662
  • Fax:
Mailing address:
  • Phone: 603-620-3662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3121329
Identifier TypeMEDICAID
Identifier StateNH
Identifier Issuer

VIII. Authorized Official

Name: JENNIFER WHITEHEAD
Title or Position: THERAPIST
Credential: LICSW, MLADC
Phone: 603-620-3662