=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730613050
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER ROBYN WHITEHEAD LMFTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2017
-----------------------------------------------------
Last Update Date | 06/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 405 NC 65
-----------------------------------------------------
City | REIDSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27320-8882
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-342-8316
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3707 HEATHROW DR
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27127-4670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 857-205-8820
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 2130
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------