Healthcare Provider Details

I. General information

NPI: 1083078117
Provider Name (Legal Business Name): JENNAH ROSE CHILDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E COLORADO BLVD STE 600
PASADENA CA
91105-3712
US

IV. Provider business mailing address

117 E COLORADO BLVD STE 600
PASADENA CA
91105-3712
US

V. Phone/Fax

Practice location:
  • Phone: 626-318-9732
  • Fax: 408-706-5574
Mailing address:
  • Phone: 833-225-4673
  • Fax: 408-706-5574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT121401
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC60539432
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: