Provider Demographics
NPI:1124539333
Name:JEG THERAPY LICENSED CLINICAL SOCIAL WORKERS, INC
Entity Type:Organization
Organization Name:JEG THERAPY LICENSED CLINICAL SOCIAL WORKERS, INC
Other - Org Name:JEG THERAPY, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / CLINICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:818-521-3867
Mailing Address - Street 1:21529 SATICOY ST APT 206
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-4962
Mailing Address - Country:US
Mailing Address - Phone:818-521-3867
Mailing Address - Fax:
Practice Address - Street 1:2659 TOWNSGATE RD STE 226
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-2755
Practice Address - Country:US
Practice Address - Phone:818-521-3867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-14
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA257691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty