Healthcare Provider Details

I. General information

NPI: 1770460883
Provider Name (Legal Business Name): RAVEN LYNN JUERGENSEN APCC, ATR-P
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2025
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2904 W SUNSET BLVD STE 6
LOS ANGELES CA
90026-7308
US

IV. Provider business mailing address

1650 N ADAMSON ST
LOS ANGELES CA
90026-7082
US

V. Phone/Fax

Practice location:
  • Phone: 213-534-7013
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPCC19492
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: