Provider Demographics
NPI:1033757299
Name:RUNNING, JENNICA CAITLIN
Entity Type:Individual
Prefix:
First Name:JENNICA
Middle Name:CAITLIN
Last Name:RUNNING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNICA
Other - Middle Name:CAITLIN
Other - Last Name:GEORGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11509 216TH ST APT 225
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90715-2521
Mailing Address - Country:US
Mailing Address - Phone:310-753-9185
Mailing Address - Fax:
Practice Address - Street 1:12395 LEWIS ST STE 202
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4694
Practice Address - Country:US
Practice Address - Phone:714-867-6384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF1867445OtherNA