Basic Information
Provider Information | |||||||||
NPI: | 1740309095 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEAVENWORTH | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | MARY | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 203 | ||||||||
Address2: |   | ||||||||
City: | LANCASTER | ||||||||
State: | CA | ||||||||
PostalCode: | 935840203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6612599439 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 21545 CENTRE POINTE PKWY | ||||||||
Address2: |   | ||||||||
City: | SANTA CLARITA | ||||||||
State: | CA | ||||||||
PostalCode: | 913502947 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6612599439 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2007 | ||||||||
LastUpdateDate: | 04/12/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 44570 | CA | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | CBSC752 | 01 | CA | LA DMH PROVIDER | OTHER |