Provider Demographics
NPI:1760965966
Name:JENKINSON, MARIA FERNANDA (CADC L CI22270620)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:FERNANDA
Last Name:JENKINSON
Suffix:
Gender:F
Credentials:CADC L CI22270620
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10520 LAKESIDE DR N UNIT J
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-5060
Mailing Address - Country:US
Mailing Address - Phone:562-388-5506
Mailing Address - Fax:
Practice Address - Street 1:2101 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-4007
Practice Address - Country:US
Practice Address - Phone:714-542-2246
Practice Address - Fax:714-906-0947
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI22270620101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACI22270620OtherCCAPP