Provider Demographics
NPI:1699286898
Name:BOUKNIGHT, JENNY ROSENBERG (LISW-CP)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:ROSENBERG
Last Name:BOUKNIGHT
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 SUNSET BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-5955
Mailing Address - Country:US
Mailing Address - Phone:803-281-6950
Mailing Address - Fax:
Practice Address - Street 1:1905 SUNSET BLVD STE C
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-5955
Practice Address - Country:US
Practice Address - Phone:803-281-6950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC267101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional