Healthcare Provider Details

I. General information

NPI: 1932471828
Provider Name (Legal Business Name): JENNIFER DOUGLASS IMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2012
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 W AVENUE J SUITE C
LANCASTER CA
93534-3443
US

IV. Provider business mailing address

921 W AVENUE J SUITE C
LANCASTER CA
93534-3443
US

V. Phone/Fax

Practice location:
  • Phone: 661-949-0131
  • Fax: 661-729-8912
Mailing address:
  • Phone: 661-949-0131
  • Fax: 661-729-8912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF 68320
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMF68320
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: