Provider Demographics
NPI:1992961890
Name:WILLSON, JENNIFER LEE (LCMFT, LAC)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LEE
Last Name:WILLSON
Suffix:
Gender:F
Credentials:LCMFT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 HILLCREST CT N
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002-9651
Mailing Address - Country:US
Mailing Address - Phone:316-871-3946
Mailing Address - Fax:
Practice Address - Street 1:433 HILLCREST CT N
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002-9651
Practice Address - Country:US
Practice Address - Phone:316-871-3946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS970106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200566650BMedicaid