Provider Demographics
NPI:1528503307
Name:CHANG, JEANIE MARIE
Entity type:Individual
Prefix:
First Name:JEANIE
Middle Name:MARIE
Last Name:CHANG
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 1:320 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-9573
Mailing Address - Country:US
Mailing Address - Phone:360-481-0270
Mailing Address - Fax:
Practice Address - Street 1:2000 RING RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-9454
Practice Address - Country:US
Practice Address - Phone:270-506-2730
Practice Address - Fax:270-900-0704
Is Sole Proprietor?:No
Enumeration Date:2017-01-03
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WALH60888116101YM0800X
WAMG60753924101YM0800X
KY260916101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health