Healthcare Provider Details

I. General information

NPI: 1497304539
Provider Name (Legal Business Name): JENNIFER MARIE MERVA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 LONG BEACH BLVD
LONG BEACH CA
90807-5062
US

IV. Provider business mailing address

3200 LONG BEACH BLVD
LONG BEACH CA
90807-5062
US

V. Phone/Fax

Practice location:
  • Phone: 562-548-6500
  • Fax:
Mailing address:
  • Phone: 562-548-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number89536
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW89536
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW109812
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: