Provider Demographics
NPI:1225221740
Name:JENKINS, PRUDENCE ANNETTE (LCSW)
Entity Type:Individual
Prefix:
First Name:PRUDENCE
Middle Name:ANNETTE
Last Name:JENKINS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:PRUDENCE
Other - Middle Name:ANNETTE
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2535 CAMINO DEL RIO S STE 303
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3757
Mailing Address - Country:US
Mailing Address - Phone:619-940-7774
Mailing Address - Fax:619-377-6701
Practice Address - Street 1:2535 CAMINO DEL RIO S STE 303
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3757
Practice Address - Country:US
Practice Address - Phone:619-940-7774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA816931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health