MEDICARE: JACOB HARRIS

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	LMFT146882	CA

General Provider Information

NPI Number	:	1639639107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB HARRIS

Provider Business Mailing Address
First Line	:	3631 MIDVALE AVE APT 3
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-6648
Country	:	US
Telephone Number	:	310-415-0225
Fax Number	:

Provider Business Practice Location Address
First Line	:	11965 VENICE BLVD STE 202
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-3954
Country	:	US
Telephone Number	:	424-290-1692
Fax Number	:

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

Provider Enumeration Date	:	03/21/2019
Last Update Date	:	07/19/2024

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