Provider Demographics
NPI:1063004182
Name:IVENER, JESSICA (LAADC)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:IVENER
Suffix:
Gender:F
Credentials:LAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28720 ROADSIDE DR STE 230
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-6008
Mailing Address - Country:US
Mailing Address - Phone:805-908-1866
Mailing Address - Fax:
Practice Address - Street 1:28720 ROADSIDE DR STE 230
Practice Address - Street 2:
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-6008
Practice Address - Country:US
Practice Address - Phone:805-908-1866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCI11100418101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)