Provider Demographics
NPI:1447842752
Name:KOMIS, JENNIFER LYNN (MAMFT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:KOMIS
Suffix:
Gender:F
Credentials:MAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13609 TERRACE CREEK DR APT 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5832
Mailing Address - Country:US
Mailing Address - Phone:502-396-0974
Mailing Address - Fax:
Practice Address - Street 1:8009 NEW LA GRANGE RD STE 1
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4791
Practice Address - Country:US
Practice Address - Phone:502-396-0974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261334101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY261334OtherMARRIAGE AND FAMILY THERAPY ASSOCIATE