MEDICARE: JENNIFER LE MA-PHAM LCSW

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	1041C0700X	Clinical Social Worker	69963	CA

General Provider Information

NPI Number	:	1164880589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER LE MA-PHAM LCSW

Provider Business Mailing Address
First Line	:	11648 GRAVOIS RD
Second Line	:	STE 140
City	:	SAINT LOUIS
State	:	MO
Zip	:	63126-3034
Country	:	US
Telephone Number	:	626-888-1112
Fax Number	:	314-394-1937

Provider Business Practice Location Address
First Line	:	4368 EAGLE ROCK BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-3211
Country	:	US
Telephone Number	:	626-888-1112
Fax Number	:	314-394-1937

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

Provider Enumeration Date	:	01/29/2016
Last Update Date	:	01/29/2016

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