Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | PSY21405 | CA |
Y | 103TC0700X | Clinical Psychologist | PSY21405 | CA |
NPI | 1003035304 |
---|---|
Provider Name | Dr. Jennie M. Mathess |
First Address | Los Angeles, CA 90042-1508 |
Second Address | Los Angeles, CA 90042-1508 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2007 |
Last Update Date | 03/10/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
PSY21405 | LICENSE NUMBER (01) | CA |