Provider Demographics
NPI:1679171300
Name:NORTHERN, JENNIFER (CIT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:NORTHERN
Suffix:
Gender:F
Credentials:CIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8911 YOUREE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-3007
Mailing Address - Country:US
Mailing Address - Phone:318-205-6691
Mailing Address - Fax:
Practice Address - Street 1:2285 BENTON RD STE D103
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3465
Practice Address - Country:US
Practice Address - Phone:318-584-7197
Practice Address - Fax:318-584-7080
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LACIT-5386101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator