Provider Demographics
NPI:1467576629
Name:SANDOVAL, JENNIFER SAMANTHA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:SAMANTHA
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8971 CAMINITO FRESCO
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1602
Mailing Address - Country:US
Mailing Address - Phone:626-590-9723
Mailing Address - Fax:
Practice Address - Street 1:1011 CAMINO DEL MAR
Practice Address - Street 2:SUITE 270
Practice Address - City:DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92014-2640
Practice Address - Country:US
Practice Address - Phone:626-590-9723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18127103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical