MEDICARE: JACQUELINE JOYCE D'MEZA 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	MFC40249	CA

General Provider Information

NPI Number	:	1194919886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE JOYCE D'MEZA LMFT

Provider Business Mailing Address
First Line	:	2600 S LA BREA AVE
Second Line	:	SUIT 11
City	:	LOS ANGELES
State	:	CA
Zip	:	90016-2807
Country	:	US
Telephone Number	:	626-393-9193
Fax Number	:	323-292-4633

Provider Business Practice Location Address
First Line	:	4247 W 61ST ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90043-3608
Country	:	US
Telephone Number	:	323-292-4633
Fax Number	:	323-292-4633

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

Provider Enumeration Date	:	09/05/2007
Last Update Date	:	09/05/2007

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