Provider Demographics
NPI:1598257099
Name:DEKLOTZ, JENNIFER LEIGH
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGH
Last Name:DEKLOTZ
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 1:26131 MARGUERITE PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-3161
Mailing Address - Country:US
Mailing Address - Phone:949-830-2846
Mailing Address - Fax:949-600-8477
Practice Address - Street 1:26131 MARGUERITE PKWY STE A
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92692-3161
Practice Address - Country:US
Practice Address - Phone:949-830-2846
Practice Address - Fax:949-600-8477
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102532106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist