Provider Demographics
NPI:1386711448
Name:HOLLIS, JENNIE LYNN (MSW INTERN)
Entity type:Individual
Prefix:MS
First Name:JENNIE
Middle Name:LYNN
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:MSW INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2149 WOODWIND DR
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-6434
Mailing Address - Country:US
Mailing Address - Phone:760-724-9112
Mailing Address - Fax:
Practice Address - Street 1:2204 NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-3615
Practice Address - Country:US
Practice Address - Phone:619-515-2355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA278291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health