Provider Demographics
NPI:1255661591
Name:MEZA-JACKSON, KEREN JACQUELINE (MA, MFTI)
Entity Type:Individual
Prefix:MRS
First Name:KEREN
Middle Name:JACQUELINE
Last Name:MEZA-JACKSON
Suffix:
Gender:F
Credentials:MA, MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-3033
Mailing Address - Country:US
Mailing Address - Phone:323-373-2400
Mailing Address - Fax:323-373-2445
Practice Address - Street 1:3031 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-3033
Practice Address - Country:US
Practice Address - Phone:323-373-2400
Practice Address - Fax:323-373-2445
Is Sole Proprietor?:No
Enumeration Date:2010-01-08
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 225400000X
CA66837106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner