Provider Demographics
NPI:1740996040
Name:WALSVICK, JENNIFER EILEEN (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:EILEEN
Last Name:WALSVICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12811 DUNAS RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-1240
Mailing Address - Country:US
Mailing Address - Phone:714-926-8270
Mailing Address - Fax:
Practice Address - Street 1:242 W MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-7715
Practice Address - Country:US
Practice Address - Phone:714-926-8270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA223641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical