Provider Demographics
NPI:1497949937
Name:PRUITT, JENNIFER MAE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MAE
Last Name:PRUITT
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 1:1215 W WEST COVINA PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2946
Mailing Address - Country:US
Mailing Address - Phone:562-477-1161
Mailing Address - Fax:
Practice Address - Street 1:1215 W WEST COVINA PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2946
Practice Address - Country:US
Practice Address - Phone:562-477-1161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24215103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical