=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821755885
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER RENEE KING LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2021
-----------------------------------------------------
Last Update Date | 11/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22949 NW 4TH PL
-----------------------------------------------------
City | NEWBERRY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32669-3499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-222-9225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22949 NW 4TH PL
-----------------------------------------------------
City | NEWBERRY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32669-3499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-222-9225
-----------------------------------------------------
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 | SW16824
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------