Provider Demographics
NPI:1083486112
Name:CORDOVA, JACQUELINE LEE (AMFT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LEE
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2638 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-4404
Mailing Address - Country:US
Mailing Address - Phone:858-729-3683
Mailing Address - Fax:
Practice Address - Street 1:13101 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5131
Practice Address - Country:US
Practice Address - Phone:310-906-0257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA141700106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist