=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346957628
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANESSA M HENNINGER PH.D., LPC, RPT-S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2022
-----------------------------------------------------
Last Update Date | 11/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 157 LEIMAMO ST
-----------------------------------------------------
City | HILO
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96720-3742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-580-8757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 157 LEIMAMO ST
-----------------------------------------------------
City | HILO
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96720-3742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-580-8757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LPC.0013396
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------