Provider Demographics
NPI:1891419917
Name:WOLDEN, JENICA
Entity Type:Individual
Prefix:
First Name:JENICA
Middle Name:
Last Name:WOLDEN
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 1:3655 RUFFIN RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1860
Mailing Address - Country:US
Mailing Address - Phone:951-813-4034
Mailing Address - Fax:
Practice Address - Street 1:3655 RUFFIN RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1860
Practice Address - Country:US
Practice Address - Phone:951-813-4034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22-223049103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst