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General NPI Number Information
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NPI Number | 1285364588
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Entity Type | Individual
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Provider Name | JESSICA HERZOG PSYD
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Gender | Female
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Dates
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Enumeration Date | 06/10/2022
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Last Update Date | 06/10/2022
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Provider Practice Location Address
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Address Line | 11726 SAN VICENTE BLVD STE 680
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City | LOS ANGELES
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State | CA
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Zip | 90049-5049
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Country | US
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Telephone | 310-435-4372
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Fax |
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Provider Business Mailing Address
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Address Line | 11726 SAN VICENTE BLVD STE 680
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City | LOS ANGELES
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State | CA
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Zip | 90049-5049
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Country | US
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Telephone | 310-435-4372
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY17935
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License Number State | CA
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