Provider Demographics
NPI:1952888695
Name:ADAMS, JENNIFER M
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:M
Last Name:ADAMS
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 1:11818 RIVERSIDE DR APT 223
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-4087
Mailing Address - Country:US
Mailing Address - Phone:727-565-8454
Mailing Address - Fax:
Practice Address - Street 1:5535 BALBOA BLVD STE 202
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1541
Practice Address - Country:US
Practice Address - Phone:818-646-7190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA138946106H00000X, 106H00000X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106H0000XMedicaid