Basic Information
| Provider Information | |||||||||
| NPI: | 1528503307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | JEANIE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 MAPLE DR | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427019573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604810270 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 320 MAPLE DR | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427019573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604810270 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2017 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | LH60888116 | WA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | MG60753924 | WA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 260916 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.