Provider Demographics
NPI:1871951095
Name:REA, JENICA ELLEN (LPC)
Entity type:Individual
Prefix:MRS
First Name:JENICA
Middle Name:ELLEN
Last Name:REA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 CRACKWILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-0028
Mailing Address - Country:US
Mailing Address - Phone:251-979-2242
Mailing Address - Fax:
Practice Address - Street 1:508 CRACKWILLOW AVE
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-0028
Practice Address - Country:US
Practice Address - Phone:251-979-2242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4242101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
13876117OtherCAQH