Healthcare Provider Details

I. General information

NPI: 1386301679
Provider Name (Legal Business Name): JENNIFER LANGHAM PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2021
Last Update Date: 11/21/2021
Certification Date: 11/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 S SAN VICENTE BLVD STE 594
LOS ANGELES CA
90048-4661
US

IV. Provider business mailing address

9663 SANTA MONICA BLVD # 227
BEVERLY HILLS CA
90210-4303
US

V. Phone/Fax

Practice location:
  • Phone: 310-275-2111
  • Fax:
Mailing address:
  • Phone: 310-275-2111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberRP200
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: