Healthcare Provider Details

I. General information

NPI: 1124644109
Provider Name (Legal Business Name): JENNIFER J WAKEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 NAPA VALLEJO HWY # 253
NAPA CA
94558-6234
US

IV. Provider business mailing address

2675 W PUEBLO AVE
NAPA CA
94558-4347
US

V. Phone/Fax

Practice location:
  • Phone: 707-255-8001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1394660620
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: