Provider Demographics
NPI:1356661227
Name:MAGENHEIMER, JESSICA MARIE (LMFT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:MAGENHEIMER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 MAIN ST # 179
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-2217
Mailing Address - Country:US
Mailing Address - Phone:310-800-1630
Mailing Address - Fax:
Practice Address - Street 1:2219 MAIN ST # 179
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-2217
Practice Address - Country:US
Practice Address - Phone:310-800-1630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT1718106H00000X
CALMFT 84128106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist