Provider Demographics
NPI:1770600470
Name:WELCH, JENNIFER ANNE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:WELCH
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 1:102 E ST
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-4633
Mailing Address - Country:US
Mailing Address - Phone:530-564-2306
Mailing Address - Fax:530-564-2306
Practice Address - Street 1:102 E ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-4633
Practice Address - Country:US
Practice Address - Phone:530-564-2306
Practice Address - Fax:530-564-2306
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2015-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83164101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94-262-3205OtherEMPLOYER IDENTIFICATION