Basic Information
| Provider Information | |||||||||
| NPI: | 1386711448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLIS | ||||||||
| FirstName: | JENNIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW INTERN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2149 WOODWIND DR | ||||||||
| Address2: | |||||||||
| City: | ENCINITAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920246434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607249112 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2204 NATIONAL AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921133615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152355 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| 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 | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 27829 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.