Basic Information
| Provider Information | |||||||||
| NPI: | 1083056279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAGUN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 823 GATEWAY CENTER WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6199064623 | ||||||||
| FaxNumber: | 6199064564 | ||||||||
| Practice Location | |||||||||
| Address1: | 4094 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921032143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152545 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2013 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 35530 | CA | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 75956 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 35530 | 01 | CA | 35530 | OTHER |