Provider Demographics
NPI:1518415413
Name:SUMNER, JENNIFER MORTENSEN (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MORTENSEN
Last Name:SUMNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4180 LA JOLLA VILLAGE DR
Mailing Address - Street 2:SUITE 240
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1402
Mailing Address - Country:US
Mailing Address - Phone:866-277-2659
Mailing Address - Fax:
Practice Address - Street 1:4180 LA JOLLA VILLAGE DR
Practice Address - Street 2:SUITE 240
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1402
Practice Address - Country:US
Practice Address - Phone:866-277-2659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22125103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical