Healthcare Provider Details

I. General information

NPI: 1174447593
Provider Name (Legal Business Name): JENNIFER HOLMBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3539 CORINTH AVE
LOS ANGELES CA
90066-2907
US

IV. Provider business mailing address

3539 CORINTH AVE
LOS ANGELES CA
90066-2907
US

V. Phone/Fax

Practice location:
  • Phone: 310-600-8277
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCS22782
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: