Provider Demographics
NPI:1174901300
Name:STEVENS, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4647 ZION AVE
Mailing Address - Street 2:2ND FLOOR, ROOM 2145
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-2507
Mailing Address - Country:US
Mailing Address - Phone:619-528-5458
Mailing Address - Fax:619-528-3542
Practice Address - Street 1:4647 ZION AVE
Practice Address - Street 2:2ND FLOOR, ROOM 2145
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-2507
Practice Address - Country:US
Practice Address - Phone:619-528-5458
Practice Address - Fax:619-528-3542
Is Sole Proprietor?:No
Enumeration Date:2015-05-07
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS242541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical