Provider Demographics
NPI:1942988332
Name:PROVENCE, JENESSA RAE
Entity Type:Individual
Prefix:MS
First Name:JENESSA
Middle Name:RAE
Last Name:PROVENCE
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 1:2312 PALERMO DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-1247
Mailing Address - Country:US
Mailing Address - Phone:619-849-9195
Mailing Address - Fax:
Practice Address - Street 1:2445 TRUXTUN RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-6153
Practice Address - Country:US
Practice Address - Phone:619-633-2119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-23-281459106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician