Provider Demographics
NPI:1194783373
Name:FLETCHER, PENNY JOSS (MA)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:JOSS
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 E 1ST ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3335
Mailing Address - Country:US
Mailing Address - Phone:714-730-7996
Mailing Address - Fax:
Practice Address - Street 1:515 E 1ST ST
Practice Address - Street 2:SUITE D
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3335
Practice Address - Country:US
Practice Address - Phone:714-730-7996
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT24489106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist