Provider Demographics
NPI:1750822946
Name:REYNOSA, JENNIFER CRISTINA
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CRISTINA
Last Name:REYNOSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 S MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-3406
Mailing Address - Country:US
Mailing Address - Phone:626-775-7888
Mailing Address - Fax:
Practice Address - Street 1:612 S MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-3406
Practice Address - Country:US
Practice Address - Phone:626-775-7888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2018-03-01
Deactivation Date:2017-12-07
Deactivation Code:
Reactivation Date:2018-01-10
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician