Provider Demographics
NPI:1073652327
Name:BLOOM-GENEVITZ, JACQUELINE LEAH (PSYD, MFT)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:LEAH
Last Name:BLOOM-GENEVITZ
Suffix:
Gender:F
Credentials:PSYD, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-1602
Mailing Address - Country:US
Mailing Address - Phone:310-582-1513
Mailing Address - Fax:
Practice Address - Street 1:12340 SANTA MONICA BLVD STE 214
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025
Practice Address - Country:US
Practice Address - Phone:310-582-1513
Practice Address - Fax:818-394-6910
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
CAMFT 43614106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist