MEDICARE: JENNA EVANS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	APCC16977	CA
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1942999743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA EVANS

Provider Business Mailing Address
First Line	:	4747 JESSIE AVE
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91942-8822
Country	:	US
Telephone Number	:	801-597-5072
Fax Number	:

Provider Business Practice Location Address
First Line	:	6977 NAVAJO RD # 467
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92119-1503
Country	:	US
Telephone Number	:	801-597-5072
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2023
Last Update Date	:	07/24/2024

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Directions to “ JENNA EVANS ” Practice Location

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