Provider Demographics
NPI:1972795896
Name:SPENCER, JENNIFER LYNN (LICSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:SPENCER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 N VERMILLION CT
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81007-1345
Mailing Address - Country:US
Mailing Address - Phone:425-903-1103
Mailing Address - Fax:
Practice Address - Street 1:503 N MAIN ST STE 324
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3139
Practice Address - Country:US
Practice Address - Phone:719-281-4789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW60157679101YM0800X, 171M00000X, 1041C0700X, 106H00000X
COCSW.09928993101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist