Healthcare Provider Details

I. General information

NPI: 1669013512
Provider Name (Legal Business Name): JENNIFER WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 12/30/2022
Certification Date: 12/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1369 FOOTHILL BLVD
LA CANADA CA
91011-2121
US

IV. Provider business mailing address

1369 FOOTHILL BLVD
LA CANADA CA
91011-2121
US

V. Phone/Fax

Practice location:
  • Phone: 818-928-4727
  • Fax:
Mailing address:
  • Phone: 818-928-4727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number136274
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: