Provider Demographics
NPI:1164929485
Name:CONNELL, JENNIFER ELISE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELISE
Last Name:CONNELL
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 1:4507 SWEET WATER ST
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-7187
Mailing Address - Country:US
Mailing Address - Phone:925-457-7417
Mailing Address - Fax:
Practice Address - Street 1:811 SAN RAMON VALLEY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-4025
Practice Address - Country:US
Practice Address - Phone:925-964-3115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician