Healthcare Provider Details

I. General information

NPI: 1194423632
Provider Name (Legal Business Name): LISA CLAIRE JORGENSEN-MATTMANN AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2023
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 TELSTAR AVE STE 101
EL MONTE CA
91731-2838
US

IV. Provider business mailing address

9040 TELSTAR AVE STE 101
EL MONTE CA
91731-2838
US

V. Phone/Fax

Practice location:
  • Phone: 626-774-5809
  • Fax:
Mailing address:
  • Phone: 626-774-5809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT136852
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number136852
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: