Provider Demographics
NPI:1184384265
Name:STATON, JENENA JAMILA
Entity type:Individual
Prefix:
First Name:JENENA
Middle Name:JAMILA
Last Name:STATON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENENA
Other - Middle Name:JAMILA
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16782 VON KARMAN AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-2417
Mailing Address - Country:US
Mailing Address - Phone:855-223-7123
Mailing Address - Fax:619-550-6368
Practice Address - Street 1:1191 CENTRAL BLVD STE A
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-2253
Practice Address - Country:US
Practice Address - Phone:855-223-7123
Practice Address - Fax:619-550-6368
Is Sole Proprietor?:No
Enumeration Date:2021-12-30
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA247200000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other