Provider Demographics
NPI:1306997663
Name:HANSON, JENNIE LEE (MA, MFT INTERN)
Entity type:Individual
Prefix:MS
First Name:JENNIE
Middle Name:LEE
Last Name:HANSON
Suffix:
Gender:F
Credentials:MA, MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18719 PALM ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6440
Mailing Address - Country:US
Mailing Address - Phone:714-968-4361
Mailing Address - Fax:
Practice Address - Street 1:3100 S HARBOR BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-6823
Practice Address - Country:US
Practice Address - Phone:714-966-8656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 41268106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist