Healthcare Provider Details

I. General information

NPI: 1386312270
Provider Name (Legal Business Name): GLENNIS JEANNE MULDOON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2021
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4874 POLK AVE
SAN DIEGO CA
92105-2026
US

IV. Provider business mailing address

PO BOX 15104
SAN DIEGO CA
92175-5104
US

V. Phone/Fax

Practice location:
  • Phone: 619-515-2426
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number29295
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number135826
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: