Provider Demographics
NPI:1447930326
Name:DUTTON, JENNIFER A
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:DUTTON
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 1:8100 LISA LN
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47122-9039
Mailing Address - Country:US
Mailing Address - Phone:502-819-0609
Mailing Address - Fax:
Practice Address - Street 1:10200 FOREST GREEN BLVD STE 112
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-5167
Practice Address - Country:US
Practice Address - Phone:800-484-5422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY257291104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker