Provider Demographics
NPI:1326398991
Name:CHINTELLA, JENISSA DAWN
Entity Type:Individual
Prefix:MS
First Name:JENISSA
Middle Name:DAWN
Last Name:CHINTELLA
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 1:165 HICKORY RIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-9759
Mailing Address - Country:US
Mailing Address - Phone:909-709-2459
Mailing Address - Fax:
Practice Address - Street 1:4337 BLACKWOOD ST.
Practice Address - Street 2:
Practice Address - City:NEWUBRY PARK
Practice Address - State:CA
Practice Address - Zip Code:91320
Practice Address - Country:US
Practice Address - Phone:909-709-2459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
SC1488103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health