Provider Demographics
NPI:1861664088
Name:MITOLO, JENNIFER (PSYD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MITOLO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1526 BROOKHOLLOW DR
Mailing Address - Street 2:SUITE 73
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-5421
Mailing Address - Country:US
Mailing Address - Phone:714-545-3390
Mailing Address - Fax:
Practice Address - Street 1:1526 BROOKHOLLOW DR
Practice Address - Street 2:SUITE 73
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5421
Practice Address - Country:US
Practice Address - Phone:714-545-3390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00448400103TC0700X
CAPSY25678103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical