Provider Demographics
NPI:1134983182
Name:GILLENWATER, JENNIFER (LMSWT, LAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GILLENWATER
Suffix:
Gender:F
Credentials:LMSWT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 S CONSTITUTION ST
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-4621
Mailing Address - Country:US
Mailing Address - Phone:620-366-9444
Mailing Address - Fax:
Practice Address - Street 1:128 S CONSTITUTION ST
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801-4621
Practice Address - Country:US
Practice Address - Phone:620-366-9444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13485-T104100000X
KS01751101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty