MEDICARE: JENNIFER LYNN KOMIS MAMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	261334	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	261334	OTHER	KY	MARRIAGE AND FAMILY THERAPY ASSOCIATE

General Provider Information

NPI Number	:	1447842752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER LYNN KOMIS MAMFT

Provider Business Mailing Address
First Line	:	13609 TERRACE CREEK DR APT 300
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40245-5832
Country	:	US
Telephone Number	:	502-396-0974
Fax Number	:

Provider Business Practice Location Address
First Line	:	8009 NEW LA GRANGE RD STE 1
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40222-4791
Country	:	US
Telephone Number	:	502-396-0974
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2021
Last Update Date	:	02/08/2021

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