Healthcare Provider Details

I. General information

NPI: 1942766548
Provider Name (Legal Business Name): JODIE SHURTLEFF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2019
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S GRAND AVE
LOS ANGELES CA
90017-4613
US

IV. Provider business mailing address

PO BOX 895
LAKEWOOD CA
90714-0895
US

V. Phone/Fax

Practice location:
  • Phone: 323-508-1202
  • Fax:
Mailing address:
  • Phone: 323-508-1202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number127617
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: