Provider Demographics
NPI:1437676053
Name:MILLS GOMEZ, JENNIFER DENISE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DENISE
Last Name:MILLS GOMEZ
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 1:1526 VIA DEL RIO
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-4726
Mailing Address - Country:US
Mailing Address - Phone:951-691-3907
Mailing Address - Fax:
Practice Address - Street 1:4000 W METROPOLITAN DR STE 404
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3504
Practice Address - Country:US
Practice Address - Phone:714-480-5160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA130368106H00000X, 106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist