Provider Demographics
NPI:1821185240
Name:COSTANZA, JENNIFER HARRISON (MA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HARRISON
Last Name:COSTANZA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 CAMINO DEL RIO S
Mailing Address - Street 2:SUITE 315
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3717
Mailing Address - Country:US
Mailing Address - Phone:619-280-3430
Mailing Address - Fax:
Practice Address - Street 1:2525 CAMINO DEL RIO S
Practice Address - Street 2:SUITE 315
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3717
Practice Address - Country:US
Practice Address - Phone:619-280-3430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 49250106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist