=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396113908
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER JANSEN LISW-CP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2015
-----------------------------------------------------
Last Update Date | 03/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 PADDOCK CHASE
-----------------------------------------------------
City | IRMO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29063-2937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-413-0497
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 851
-----------------------------------------------------
City | IRMO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29063-0851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-470-5895
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 11692
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------