Provider Demographics
NPI:1245547819
Name:FETNER, JESSICA ELYSE (BSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELYSE
Last Name:FETNER
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34816 CALLE DEL SOL
Mailing Address - Street 2:
Mailing Address - City:CAPISTRANO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92624-1553
Mailing Address - Country:US
Mailing Address - Phone:949-291-6271
Mailing Address - Fax:
Practice Address - Street 1:26891 SPRING ST
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-2692
Practice Address - Country:US
Practice Address - Phone:949-496-2931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker