Provider Demographics
NPI:1871771766
Name:PROUDFOOT, JENNIFER DIANA
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANA
Last Name:PROUDFOOT
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 1:5200 PARK RD STE 119
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3650
Mailing Address - Country:US
Mailing Address - Phone:704-582-2582
Mailing Address - Fax:704-527-5302
Practice Address - Street 1:5200 PARK RD STE 119
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3650
Practice Address - Country:US
Practice Address - Phone:704-582-2582
Practice Address - Fax:704-527-5302
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-04
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6104127Medicaid