Provider Demographics
NPI:1679721450
Name:HALL, JENNIFER NICOLE (MFT INTERN)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:HALL
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3124
Mailing Address - Country:US
Mailing Address - Phone:562-485-3025
Mailing Address - Fax:562-426-4661
Practice Address - Street 1:1301 PINE AVENUE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813
Practice Address - Country:US
Practice Address - Phone:562-216-1700
Practice Address - Fax:562-426-4661
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF77297106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPCY2034OtherPCY