Provider Demographics
NPI:1316216021
Name:JERNAZIAN, LEVON (PHD)
Entity Type:Individual
Prefix:DR
First Name:LEVON
Middle Name:
Last Name:JERNAZIAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 N BRAND BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-3000
Mailing Address - Country:US
Mailing Address - Phone:818-547-6929
Mailing Address - Fax:818-547-5853
Practice Address - Street 1:1139 N BRAND BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-3000
Practice Address - Country:US
Practice Address - Phone:818-547-6929
Practice Address - Fax:818-547-5853
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-26
Last Update Date:2011-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 12610103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY12610OtherBOARD OF PSYCHOLOGY