Provider Demographics
NPI:1356874135
Name:WHALEN, JENNIFER M
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:WHALEN
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 1:17800 US HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-1221
Mailing Address - Country:US
Mailing Address - Phone:760-946-8200
Mailing Address - Fax:760-946-8208
Practice Address - Street 1:17800 US HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1221
Practice Address - Country:US
Practice Address - Phone:760-946-8200
Practice Address - Fax:760-946-8208
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36783101YM0800X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health