MEDICARE: MRS. JESSICA BLATT EZOR LMFT #79983

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	B4946538	CA

General Provider Information

NPI Number	:	1689970964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA BLATT EZOR LMFT #79983

Provider Business Mailing Address
First Line	:	10541 STRATHMORE DR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-2540
Country	:	US
Telephone Number	:	310-430-1194
Fax Number	:

Provider Business Practice Location Address
First Line	:	1772 S ROBERTSON BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-4316
Country	:	US
Telephone Number	:	310-694-5590
Fax Number	:

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

Provider Enumeration Date	:	02/03/2011
Last Update Date	:	11/12/2015

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