MEDICARE: JENNIFER REZA M.A. LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	LMFT 87609	CA

General Provider Information

NPI Number	:	1073811154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER REZA M.A. LMFT

Provider Business Mailing Address
First Line	:	1401 N EL CAMINO REAL
Second Line	:	SUITE 106
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92672-4985
Country	:	US
Telephone Number	:	949-287-4289
Fax Number	:

Provider Business Practice Location Address
First Line	:	1401 N EL CAMINO REAL
Second Line	:	SUITE 106
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92672-4985
Country	:	US
Telephone Number	:	949-287-4289
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2011
Last Update Date	:	07/23/2015

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