Provider Demographics
NPI:1275336414
Name:LOCK, MADELINE JENNINGS
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:JENNINGS
Last Name:LOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4353 PARK BLVD APT 526
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2570
Mailing Address - Country:US
Mailing Address - Phone:703-638-8400
Mailing Address - Fax:
Practice Address - Street 1:2851 CAMINO DEL RIO S STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3814
Practice Address - Country:US
Practice Address - Phone:703-638-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA151781106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist