Healthcare Provider Details

I. General information

NPI: 1447613427
Provider Name (Legal Business Name): JENNIFER IRENE PROVOST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2016
Last Update Date: 03/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2844 COLOMA ST
PLACERVILLE CA
95667-4406
US

IV. Provider business mailing address

5725 MAIN AVE APT 22
ORANGEVALE CA
95662-5446
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-9240
  • Fax:
Mailing address:
  • Phone: 916-204-4293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: