Provider Demographics
NPI:1689304412
Name:PAGE, GENNIFER JEANETTE
Entity Type:Individual
Prefix:
First Name:GENNIFER
Middle Name:JEANETTE
Last Name:PAGE
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 1:2423 W MARCH LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6469
Mailing Address - Country:US
Mailing Address - Phone:209-478-9862
Mailing Address - Fax:
Practice Address - Street 1:2423 W MARCH LN STE 200
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8250
Practice Address - Country:US
Practice Address - Phone:209-478-9862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD3535311101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health