Healthcare Provider Details

I. General information

NPI: 1063339174
Provider Name (Legal Business Name): JEREMY LARSON MARRIAGE AND FAMILY THERAPY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18122 CARMENITA RD UNIT 3643
CERRITOS CA
90703-9998
US

IV. Provider business mailing address

18122 CARMENITA RD UNIT 3643
CERRITOS CA
90703-9998
US

V. Phone/Fax

Practice location:
  • Phone: 562-232-9688
  • Fax:
Mailing address:
  • Phone: 562-232-9688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: JEREMY LARSON
Title or Position: CEO/PRESIDENT
Credential: LMFT, CSAT
Phone: 562-232-9688