Provider Demographics
NPI:1760791537
Name:MEDINA, JENNIFER LYNN (MA, PCCI)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MA, PCCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 CRANE ST
Mailing Address - Street 2:STE 205
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-4257
Mailing Address - Country:US
Mailing Address - Phone:650-319-7225
Mailing Address - Fax:650-618-5556
Practice Address - Street 1:1225 CRANE ST
Practice Address - Street 2:STE 205
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4257
Practice Address - Country:US
Practice Address - Phone:650-319-7225
Practice Address - Fax:650-618-5556
Is Sole Proprietor?:No
Enumeration Date:2010-09-28
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA1035101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)