Provider Demographics
NPI:1952708307
Name:JENNINGS, JUSTEEN (MA)
Entity Type:Individual
Prefix:MRS
First Name:JUSTEEN
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MISS
Other - First Name:JUSTEEN
Other - Middle Name:
Other - Last Name:JACOBI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:3340 KEMPER STREET SUITE 105
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110
Mailing Address - Country:US
Mailing Address - Phone:619-523-8121
Mailing Address - Fax:
Practice Address - Street 1:3340 KEMPER STREET SUITE 105
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110
Practice Address - Country:US
Practice Address - Phone:619-523-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPCCI 1795101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA37378100Medicaid