=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073647053
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNETTE ALLEN JENKINS LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 04/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 229 S RIVERSIDE AVE SUITE M
-----------------------------------------------------
City | RIALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92376-6467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-873-8363
-----------------------------------------------------
Fax | 909-873-5039
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2918
-----------------------------------------------------
City | BIG BEAR LAKE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92315-2918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-873-8363
-----------------------------------------------------
Fax | 909-873-5039
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC28241
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------