MEDICARE: DR. LEVON JERNAZIAN PH.D.

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	103TC0700X	Clinical Psychologist	PSY 12610	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PSY12610	OTHER	CA	BOARD OF PSYCHOLOGY

General Provider Information

NPI Number	:	1316216021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEVON JERNAZIAN PH.D.

Provider Business Mailing Address
First Line	:	1139 N BRAND BLVD
Second Line	:	SUITE C
City	:	GLENDALE
State	:	CA
Zip	:	91202-3000
Country	:	US
Telephone Number	:	818-547-6929
Fax Number	:	818-547-5853

Provider Business Practice Location Address
First Line	:	1139 N BRAND BLVD
Second Line	:	SUITE C
City	:	GLENDALE
State	:	CA
Zip	:	91202-3000
Country	:	US
Telephone Number	:	818-547-6929
Fax Number	:	818-547-5853

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

Provider Enumeration Date	:	12/26/2011
Last Update Date	:	12/26/2011

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