Provider Demographics
NPI:1043939192
Name:MIRMIRA, JENNIFER LEIGH
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGH
Last Name:MIRMIRA
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:PO BOX 420276
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92142-0276
Mailing Address - Country:US
Mailing Address - Phone:323-552-9070
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 371
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94083-0371
Practice Address - Country:US
Practice Address - Phone:415-712-2328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA144523106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist