Provider Demographics
NPI:1730440009
Name:GULLEY, JENNIFER ALICIA
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ALICIA
Last Name:GULLEY
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 1:730 MEDICAL CENTER COURT
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-3139
Mailing Address - Country:US
Mailing Address - Phone:619-397-6932
Mailing Address - Fax:
Practice Address - Street 1:730 MEDICAL CENTER COURT
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-3139
Practice Address - Country:US
Practice Address - Phone:619-397-6932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA74846106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)