Provider Demographics
NPI:1831219773
Name:JENNY ELLINGSEN DBA GENESIS GROUP
Entity type:Organization
Organization Name:JENNY ELLINGSEN DBA GENESIS GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:RODELANDER
Authorized Official - Last Name:ELLINGSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:760-729-5705
Mailing Address - Street 1:3150 EL CAMINO REAL
Mailing Address - Street 2:SUITE E
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-2110
Mailing Address - Country:US
Mailing Address - Phone:760-729-5705
Mailing Address - Fax:760-632-0223
Practice Address - Street 1:3150 EL CAMINO REAL
Practice Address - Street 2:SUITE E
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2110
Practice Address - Country:US
Practice Address - Phone:760-729-5705
Practice Address - Fax:760-632-0223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA# MFC19117106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty