MEDICARE: DR. JEFFREY JOSEPH REA PSYD

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	23854	CA

General Provider Information

NPI Number	:	1396046660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY JOSEPH REA PSYD

Provider Business Mailing Address
First Line	:	626 WILSHIRE BLVD
Second Line	:	STE 910
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-3209
Country	:	US
Telephone Number	:	213-293-4925
Fax Number	:	213-622-5633

Provider Business Practice Location Address
First Line	:	626 WILSHIRE BLVD
Second Line	:	STE 910
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-3209
Country	:	US
Telephone Number	:	213-293-4925
Fax Number	:	213-622-5633

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

Provider Enumeration Date	:	11/03/2010
Last Update Date	:	10/01/2013

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