=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427293224
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFREY J. WOOD, PH.D., A PSYCHOLOGY CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2008
-----------------------------------------------------
Last Update Date | 09/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10436 SANTA MONICA BLVD 3050
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025-6933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-701-1983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10436 SANTA MONICA BLVD 3050
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025-6933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-701-1983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. JEFFREY WOOD
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 310-701-1983
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | PSY19857
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------