Provider Demographics
NPI:1043556947
Name:EVANS, JENNY (PHD)
Entity type:Individual
Prefix:DR
First Name:JENNY
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:681 SAN RODOLFO DR # 1006
Mailing Address - Street 2:
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-2001
Mailing Address - Country:US
Mailing Address - Phone:206-290-1890
Mailing Address - Fax:
Practice Address - Street 1:681 SAN RODOLFO DR # 1088
Practice Address - Street 2:
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-2001
Practice Address - Country:US
Practice Address - Phone:206-290-1890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-20
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60962668103TC0700X
CA29405103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid