Provider Demographics
NPI:1861742413
Name:ANTONIO, JENNIFER E
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:ANTONIO
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 1:500 JEFFERSON BLVD
Mailing Address - Street 2:SUITE B160
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95605-2350
Mailing Address - Country:US
Mailing Address - Phone:916-427-7141
Mailing Address - Fax:
Practice Address - Street 1:500 JEFFERSON BLVD
Practice Address - Street 2:SUITE B160
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95605-2350
Practice Address - Country:US
Practice Address - Phone:916-427-7141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA602861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical