Healthcare Provider Details

I. General information

NPI: 1851609812
Provider Name (Legal Business Name): JASON THOMAS LEP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2010
Last Update Date: 09/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6210 WILSHIRE BLVD 207
LOS ANGELES CA
90048-5105
US

IV. Provider business mailing address

12211 LAUREL TERRACE DR
STUDIO CITY CA
91604-3608
US

V. Phone/Fax

Practice location:
  • Phone: 323-702-2706
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3167
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: