Healthcare Provider Details

I. General information

NPI: 1871844084
Provider Name (Legal Business Name): JENNIFER ANN BIRDSALL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2012
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4929 WILSHIRE BLVD SUITE NUMBER 510
LOS ANGELES CA
90010-3808
US

IV. Provider business mailing address

4929 WILSHIRE BLVD SUITE NUMBER 510
LOS ANGELES CA
90010-3808
US

V. Phone/Fax

Practice location:
  • Phone: 562-904-3999
  • Fax: 855-688-6746
Mailing address:
  • Phone: 562-904-3999
  • Fax: 855-688-6746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number019757
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY26694
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: