Provider Demographics
NPI:1760614366
Name:DAWN, JENNIFER PHOENIX (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PHOENIX
Last Name:DAWN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 LAKE TAHOE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6305
Mailing Address - Country:US
Mailing Address - Phone:530-573-7970
Mailing Address - Fax:
Practice Address - Street 1:1900 LAKE TAHOE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6305
Practice Address - Country:US
Practice Address - Phone:530-573-7970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-14
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical