Provider Demographics
NPI:1962248278
Name:CASAGRANDA, JENNIFER KINNER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KINNER
Last Name:CASAGRANDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:DIANE
Other - Last Name:KINNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:119 BENEDICT CT
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-5307
Mailing Address - Country:US
Mailing Address - Phone:707-373-8739
Mailing Address - Fax:
Practice Address - Street 1:1080 MARINA VILLAGE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1078
Practice Address - Country:US
Practice Address - Phone:510-769-4106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-05
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95382973163W00000X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health