Provider Demographics
NPI:1619384989
Name:MATHIS, JENNIFER (PHD, LPCC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
Credentials:PHD, LPCC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:MARRERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 664
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92049-0664
Mailing Address - Country:US
Mailing Address - Phone:760-496-9600
Mailing Address - Fax:858-408-6504
Practice Address - Street 1:815 MISSION AVE STE 208
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-2841
Practice Address - Country:US
Practice Address - Phone:760-496-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-17
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPCC409106H00000X
HIMHC 306101YM0800X
AZLPC 14506101YP2500X
CALPC 409101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional