Provider Demographics
NPI:1225272883
Name:JENNER, MARCIE DEBRA (PHD, MFT)
Entity Type:Individual
Prefix:DR
First Name:MARCIE
Middle Name:DEBRA
Last Name:JENNER
Suffix:
Gender:F
Credentials:PHD, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1278 GLENNEYRE ST # 171
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-3103
Mailing Address - Country:US
Mailing Address - Phone:949-497-2635
Mailing Address - Fax:949-497-2635
Practice Address - Street 1:2001 S BARRINGTON AVE STE 203
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5385
Practice Address - Country:US
Practice Address - Phone:310-497-6513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 18386106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist