Provider Demographics
NPI:1306473897
Name:DAVITT, JENNA (LCSW)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:DAVITT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6835 CODY LN
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-2653
Mailing Address - Country:US
Mailing Address - Phone:815-520-8526
Mailing Address - Fax:
Practice Address - Street 1:6007 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209-1337
Practice Address - Country:US
Practice Address - Phone:815-520-8526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490203771041C0700X
TN70061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical