=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396282430
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER BUNN LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2017
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 609 CHURCH ST
-----------------------------------------------------
City | BLACKSTONE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23824-1607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-294-7486
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 505 COLLEGE AVE
-----------------------------------------------------
City | BLACKSTONE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23824-2429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-294-7486
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0701006965
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------