1053780064 NPI number — JENNIFER DEFOREST MFT INTERN

Table of content: JENNIFER DEFOREST MFT INTERN (NPI 1053780064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053780064 NPI number — JENNIFER DEFOREST MFT INTERN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEFOREST
Provider First Name:
JENNIFER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MFT INTERN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053780064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4492
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATSWORTH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91313-4492
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-282-3554
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7461 BEVERLY BLVD
Provider Second Line Business Practice Location Address:
UNIT 405
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90036-2704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-939-6355
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  70261 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)