Provider Demographics
NPI:1265478754
Name:MEDVENE, JAIME ELIZABETH (PHD)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:ELIZABETH
Last Name:MEDVENE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30200 AGOURA RD
Mailing Address - Street 2:STE 200
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-5433
Mailing Address - Country:US
Mailing Address - Phone:818-981-7845
Mailing Address - Fax:818-981-7849
Practice Address - Street 1:17337 VENTURA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-3903
Practice Address - Country:US
Practice Address - Phone:818-981-7845
Practice Address - Fax:818-981-7849
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13740103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY137401Medicaid
CAPSY137401Medicaid
BK975ZMedicare PIN