Provider Demographics
NPI:1720627433
Name:TOBON, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:TOBON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19229 NORDHOFF ST APT 2
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-3657
Mailing Address - Country:US
Mailing Address - Phone:818-271-4855
Mailing Address - Fax:
Practice Address - Street 1:9650 ZELZAH AVE
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-2003
Practice Address - Country:US
Practice Address - Phone:818-993-9311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-27
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X, 171M00000X, 225400000X, 390200000X
CAAMFT149361106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL