Healthcare Provider Details

I. General information

NPI: 1750802658
Provider Name (Legal Business Name): KATHY MICHELE JAMIESON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19321 VICTORY BLVD
RESEDA CA
91335-6302
US

IV. Provider business mailing address

19321 VICTORY BLVD STE 110
RESEDA CA
91335-6302
US

V. Phone/Fax

Practice location:
  • Phone: 818-708-4500
  • Fax:
Mailing address:
  • Phone: 818-708-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW111264
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: