MEDICARE: JENNIFER BLAIR TANNENBAUM 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	129287	CA

General Provider Information

NPI Number	:	1902565351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER BLAIR TANNENBAUM LMFT

Provider Business Mailing Address
First Line	:	29302 LARO DR
Second Line	:
City	:	AGOURA HILLS
State	:	CA
Zip	:	91301-1608
Country	:	US
Telephone Number	:	818-661-7082
Fax Number	:

Provider Business Practice Location Address
First Line	:	3569 VINTON AVE APT 108
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-4868
Country	:	US
Telephone Number	:	818-661-7082
Fax Number	:

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

Provider Enumeration Date	:	12/13/2021
Last Update Date	:	12/13/2021

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