Provider Demographics
NPI:1861664088
Name:MITOLO, JENNIFER L (PSYD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:MITOLO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 BARRANCA PKWY STE 260
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-4780
Mailing Address - Country:US
Mailing Address - Phone:925-282-1778
Mailing Address - Fax:415-296-5299
Practice Address - Street 1:4040 BARRANCA PKWY STE 260
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4780
Practice Address - Country:US
Practice Address - Phone:925-282-1778
Practice Address - Fax:415-296-5299
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25678103TC0700X
NJ35SI00448400103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical