Provider Demographics
NPI:1720420136
Name:COLWELL, JEANNINE LOUISE-WISNIEW (IMF # 72682)
Entity Type:Individual
Prefix:MRS
First Name:JEANNINE
Middle Name:LOUISE-WISNIEW
Last Name:COLWELL
Suffix:
Gender:F
Credentials:IMF # 72682
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23981 SHERILTON VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:DESCANSO
Mailing Address - State:CA
Mailing Address - Zip Code:91916-9740
Mailing Address - Country:US
Mailing Address - Phone:619-445-0405
Mailing Address - Fax:
Practice Address - Street 1:23981 SHERILTON VALLEY RD
Practice Address - Street 2:
Practice Address - City:DESCANSO
Practice Address - State:CA
Practice Address - Zip Code:91916-9740
Practice Address - Country:US
Practice Address - Phone:619-445-0405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF # 72682106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist