Provider Demographics
NPI:1396579611
Name:BICKNELL, JENNIE LANE L (RADT)
Entity type:Individual
Prefix:
First Name:JENNIE LANE
Middle Name:L
Last Name:BICKNELL
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:JENNIE
Other - Middle Name:LANE
Other - Last Name:BICKNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADAC
Mailing Address - Street 1:1208 SIR FRANCIS DRAKE BLVD APT 4
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-1745
Mailing Address - Country:US
Mailing Address - Phone:415-250-2761
Mailing Address - Fax:
Practice Address - Street 1:603 D ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3719
Practice Address - Country:US
Practice Address - Phone:415-454-9444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1518840823101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)