Healthcare Provider Details

I. General information

NPI: 1700173598
Provider Name (Legal Business Name): JENNIFER MARIE MIELE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 HUNTINGTON DR STE 101
SOUTH PASADENA CA
91030-5444
US

IV. Provider business mailing address

1499 HUNTINGTON DR STE 101
SOUTH PASADENA CA
91030-5444
US

V. Phone/Fax

Practice location:
  • Phone: 626-403-4370
  • Fax: 626-403-4260
Mailing address:
  • Phone: 626-403-4370
  • Fax: 626-403-4260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 25247
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: