Provider Demographics
NPI:1619204831
Name:POWELL, JENNINE ELISE (MA, MFT)
Entity Type:Individual
Prefix:MRS
First Name:JENNINE
Middle Name:ELISE
Last Name:POWELL
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 CAMINO DEL RIO S STE 215
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3837
Mailing Address - Country:US
Mailing Address - Phone:619-558-0001
Mailing Address - Fax:
Practice Address - Street 1:3333 CAMINO DEL RIO S STE 215
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3837
Practice Address - Country:US
Practice Address - Phone:619-471-7104
Practice Address - Fax:619-297-4496
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC#47653106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist