Provider Demographics
NPI:1447613427
Name:PROVOST, JENNIFER IRENE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:IRENE
Last Name:PROVOST
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 1:5725 MAIN AVE APT 22
Mailing Address - Street 2:
Mailing Address - City:ORANGEVALE
Mailing Address - State:CA
Mailing Address - Zip Code:95662-5446
Mailing Address - Country:US
Mailing Address - Phone:916-204-4293
Mailing Address - Fax:
Practice Address - Street 1:2844 COLOMA ST
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-4406
Practice Address - Country:US
Practice Address - Phone:530-626-9240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)