Provider Demographics
NPI:1073647053
Name:JENKINS, ANNETTE ALLEN (LMFT)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:ALLEN
Last Name:JENKINS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:ANNETTE
Other - Middle Name:ALLEN
Other - Last Name:FEMI-GRAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:PO BOX 2918
Mailing Address - Street 2:
Mailing Address - City:BIG BEAR LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92315-2918
Mailing Address - Country:US
Mailing Address - Phone:909-873-8363
Mailing Address - Fax:909-873-5039
Practice Address - Street 1:229 S RIVERSIDE AVE
Practice Address - Street 2:SUITE M
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-6467
Practice Address - Country:US
Practice Address - Phone:909-873-8363
Practice Address - Fax:909-873-5039
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC28241106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist