Provider Demographics
NPI:1396082434
Name:CANOBBIO, JENNIFER M WALLACE (MSW, ASW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M WALLACE
Last Name:CANOBBIO
Suffix:
Gender:F
Credentials:MSW, ASW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:627 CABRILLO AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1107
Mailing Address - Country:US
Mailing Address - Phone:408-821-6832
Mailing Address - Fax:
Practice Address - Street 1:627 CABRILLO AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1107
Practice Address - Country:US
Practice Address - Phone:408-821-6832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW332421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical