Provider Demographics
NPI:1871642025
Name:BORDENAVE, JENNIFER ANNETTE (MS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNETTE
Last Name:BORDENAVE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 E. CENTER STREET
Mailing Address - Street 2:#3
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336
Mailing Address - Country:US
Mailing Address - Phone:209-239-5553
Mailing Address - Fax:209-239-5978
Practice Address - Street 1:129 E CENTER ST STE 3
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4648
Practice Address - Country:US
Practice Address - Phone:209-239-5553
Practice Address - Fax:209-239-5978
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 44782106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist