MEDICARE: DR. JENNA I METELLUS PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor		CA
2	225C00000X	Rehabilitation Counselor
3	390200000X	Student in an Organized Health Care Education/Training Program
4	103TC0700X	Clinical Psychologist	30486	CA

General Provider Information

NPI Number	:	1891043865
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNA I METELLUS PSYD

Provider Business Mailing Address
First Line	:	PO BOX 57064
Second Line	:
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91413-2064
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6320 CANOGA AVE
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91367-2526
Country	:	US
Telephone Number	:	818-227-5000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2012
Last Update Date	:	04/21/2020

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