Provider Demographics
NPI:1447007570
Name:CONRAD, JENNIFER DIANNE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANNE
Last Name:CONRAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 N SUMNER ST
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:NC
Mailing Address - Zip Code:27576-2530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7621 PURFOY RD STE 105B
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-6985
Practice Address - Country:US
Practice Address - Phone:833-749-4584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18124101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health