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General NPI Number Information
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NPI Number | 1083076368
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Entity Type | Individual
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Provider Name | JASON ICKOVITZ LMFT
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Gender | Male
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Dates
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Enumeration Date | 03/24/2016
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Last Update Date | 03/24/2016
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Provider Practice Location Address
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Address Line | 8170 BEVERLY BLVD 203
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City | LOS ANGELES
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State | CA
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Zip | 90048-4524
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Country | US
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Telephone | 424-274-1564
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Fax |
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Provider Business Mailing Address
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Address Line | 317 N OGDEN DR
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City | LOS ANGELES
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State | CA
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Zip | 90036-2130
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Country | US
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Telephone | 310-650-2501
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 80112
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License Number State | CA
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