Provider Demographics
NPI:1083076368
Name:ICKOVITZ, JASON (LMFT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:ICKOVITZ
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 N OGDEN DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-2130
Mailing Address - Country:US
Mailing Address - Phone:310-650-2501
Mailing Address - Fax:
Practice Address - Street 1:8170 BEVERLY BLVD
Practice Address - Street 2:203
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4524
Practice Address - Country:US
Practice Address - Phone:424-274-1564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80112101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health