Provider Demographics
NPI:1275906299
Name:BLAIR, JENNIFER ST (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ST
Last Name:BLAIR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:SARAH THEA
Other - Last Name:WILLIAMSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11949 JEFFERSON BLVD
Mailing Address - Street 2:106
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-6336
Mailing Address - Country:US
Mailing Address - Phone:323-736-1463
Mailing Address - Fax:
Practice Address - Street 1:11949 JEFFERSON BLVD
Practice Address - Street 2:106
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-6336
Practice Address - Country:US
Practice Address - Phone:323-736-1463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-12
Last Update Date:2016-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA664311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical