Provider Demographics
NPI:1689227654
Name:OTIS, JENNIFER RACHEL (LMSW)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RACHEL
Last Name:OTIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2138 S WHITE OAK CIR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207-5253
Mailing Address - Country:US
Mailing Address - Phone:316-689-1353
Mailing Address - Fax:
Practice Address - Street 1:6611 E CENTRAL AVE STE C
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-1937
Practice Address - Country:US
Practice Address - Phone:316-689-1353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS9965104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker