{
"Npi": {
"NPI": "1275000929",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "TEDJAKESUMA",
"FirstName": "CLARA",
"MiddleName": "DAWN",
"NamePrefix": "MRS.",
"NameSuffix": null,
"Credential": "AMFT",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "MYERS",
"OtherFirstName": "CLARA",
"OtherMiddleName": "DAWN",
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "4737 EASTBROOK AVE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "LAKEWOOD",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "90713-2327",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "562-407-4181",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "18 E MAIN ST STE 216",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "GREENFIELD",
"PracticeLocationAddressStateName": "IN",
"PracticeLocationAddressPostalCode": "46140-5541",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "317-649-4311",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "10/31/2018",
"LastUpdateDate": "08/25/2021",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "106H00000X",
"TaxonomyName": "Marriage & Family Therapist",
"LicenseNumber": "IMF96958",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}