Provider Demographics
NPI:1003370586
Name:VALLECILLO, JENNIFER FERNANDA
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:FERNANDA
Last Name:VALLECILLO
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 1:24425 WOOLSEY CANYON RD SPC 106
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-6928
Mailing Address - Country:US
Mailing Address - Phone:818-331-3816
Mailing Address - Fax:
Practice Address - Street 1:566 S BRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-4002
Practice Address - Country:US
Practice Address - Phone:818-898-0223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program