Provider Demographics
NPI:1861846354
Name:HARE, JENNIFER LYNN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:HARE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22471 ASPAN SREET
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630
Mailing Address - Country:US
Mailing Address - Phone:949-458-2715
Mailing Address - Fax:949-458-3583
Practice Address - Street 1:22471 ASPAN ST STE 103
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1644
Practice Address - Country:US
Practice Address - Phone:949-458-2715
Practice Address - Fax:949-458-3583
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA917651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical