Provider Demographics
NPI:1669106696
Name:JENNINGS, LISA K (PHD, LICSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:PHD, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6475 E PACIFIC COAST HWY # 369
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-4201
Mailing Address - Country:US
Mailing Address - Phone:512-496-9978
Mailing Address - Fax:
Practice Address - Street 1:6475 E PACIFIC COAST HWY # 369
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-4201
Practice Address - Country:US
Practice Address - Phone:512-496-9978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2022-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX509321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical