Provider Demographics
NPI:1346558772
Name:PROVINSE, JENNAFER ROCHELLE
Entity Type:Individual
Prefix:
First Name:JENNAFER
Middle Name:ROCHELLE
Last Name:PROVINSE
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 1:2201 E WILLOW ST # 169
Mailing Address - Street 2:
Mailing Address - City:SIGNAL HILL
Mailing Address - State:CA
Mailing Address - Zip Code:90755-2148
Mailing Address - Country:US
Mailing Address - Phone:562-449-9258
Mailing Address - Fax:
Practice Address - Street 1:15720 VENTURA BLVD STE 420
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4711
Practice Address - Country:US
Practice Address - Phone:562-449-9258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1178561041C0700X
CA82093104100000X, 101YM0800X
CA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health