Healthcare Provider Details

I. General information

NPI: 1205968179
Provider Name (Legal Business Name): JENNA LYNN BALSAVAGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 03/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14660 OXNARD ST
VAN NUYS CA
91411-3119
US

IV. Provider business mailing address

5365 OSTROM AVE
ENCINO CA
91316-2631
US

V. Phone/Fax

Practice location:
  • Phone: 818-907-4836
  • Fax: 818-376-0044
Mailing address:
  • Phone: 818-486-3401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 24350
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: