Basic Information
| Provider Information | |||||||||
| NPI: | 1518415413 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUMNER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MORTENSEN | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4180 LA JOLLA VILLAGE DR | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920371402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662772659 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4180 LA JOLLA VILLAGE DR | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920371402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662772659 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2016 | ||||||||
| LastUpdateDate: | 03/24/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY22125 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.