Healthcare Provider Details

I. General information

NPI: 1366943060
Provider Name (Legal Business Name): JASPER ESTABILLO PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 WESTWOOD PLZ # 48-240
LOS ANGELES CA
90024-5055
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 400
LOS ANGELES CA
90095-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-9989
  • Fax: 310-206-4446
Mailing address:
  • Phone: 310-301-8707
  • Fax: 310-301-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY32883
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number32883
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: