Healthcare Provider Details

I. General information

NPI: 1184918260
Provider Name (Legal Business Name): JENNIFER ENID SPENCER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 OCEAN AVE
SAN FRANCISCO CA
94112-1727
US

IV. Provider business mailing address

1601 DONNER AVE SUITE 3
SAN FRANCISCO CA
94124-3276
US

V. Phone/Fax

Practice location:
  • Phone: 415-452-2200
  • Fax: 415-334-5712
Mailing address:
  • Phone: 415-762-8391
  • Fax: 415-822-8262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRIS1410061011
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberRIS1410061011
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: