Provider Demographics
NPI:1356685689
Name:MEDINA, JENNIFER (ASW, MSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:ASW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3680 E IMPERIAL HWY STE 220
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-2663
Mailing Address - Country:US
Mailing Address - Phone:323-769-7163
Mailing Address - Fax:323-886-5326
Practice Address - Street 1:3680 E IMPERIAL HWY STE 220
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2663
Practice Address - Country:US
Practice Address - Phone:323-769-7163
Practice Address - Fax:310-886-5326
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85616101YM0800X, 104100000X
CA34113104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health