Provider Demographics
NPI:1356466965
Name:GHOLSON, JESSICA (MFT INTERN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GHOLSON
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 AERICK ST
Mailing Address - Street 2:APT 3
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1944
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11600 ELDRIDGE AVE
Practice Address - Street 2:
Practice Address - City:LAKE VIEW TERRACE
Practice Address - State:CA
Practice Address - Zip Code:91342-6506
Practice Address - Country:US
Practice Address - Phone:818-686-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48917106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist