Basic Information
| Provider Information | |||||||||
| NPI: | 1932471828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGLASS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | IMFT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 921 W AVENUE J | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935343443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619490131 | ||||||||
| FaxNumber: | 6617298912 | ||||||||
| Practice Location | |||||||||
| Address1: | 921 W AVENUE J | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935343443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619490131 | ||||||||
| FaxNumber: | 6617298912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2012 | ||||||||
| LastUpdateDate: | 05/29/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF 68320 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | IMF68320 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.