Provider Demographics
NPI:1740309095
Name:LEAVENWORTH, JENNIFER MARY (LMFT)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MARY
Last Name:LEAVENWORTH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 203
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93584-0203
Mailing Address - Country:US
Mailing Address - Phone:661-259-9439
Mailing Address - Fax:
Practice Address - Street 1:21545 CENTRE POINTE PKWY
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91350-2947
Practice Address - Country:US
Practice Address - Phone:661-259-9439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44570106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACBSC752OtherLA DMH PROVIDER
CA00007473Medicare ID - Type UnspecifiedMEDICAL