Provider Demographics
NPI:1578579439
Name:VINCENT, JENNIFER (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VINCENT
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 1:1247 7TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-1642
Mailing Address - Country:US
Mailing Address - Phone:310-451-7871
Mailing Address - Fax:310-455-2969
Practice Address - Street 1:1247 7TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1642
Practice Address - Country:US
Practice Address - Phone:310-451-7871
Practice Address - Fax:310-455-2969
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16386103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY16386OtherLICENSE NUMBER