Provider Demographics
NPI:1447918867
Name:OTWELL, JENNIFER LUCY (LICSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LUCY
Last Name:OTWELL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LUCY
Other - Last Name:WAITES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:114 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-1415
Mailing Address - Country:US
Mailing Address - Phone:205-283-7112
Mailing Address - Fax:
Practice Address - Street 1:114 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:TRUSSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35173-1415
Practice Address - Country:US
Practice Address - Phone:205-283-7112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1615-4225C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical