Provider Demographics
NPI:1356866941
Name:JEZEH, BERADIN JEBRAEIL
Entity Type:Individual
Prefix:
First Name:BERADIN
Middle Name:JEBRAEIL
Last Name:JEZEH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2309 DALY ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-2230
Mailing Address - Country:US
Mailing Address - Phone:323-222-4591
Mailing Address - Fax:
Practice Address - Street 1:2309 DALY ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90031-2230
Practice Address - Country:US
Practice Address - Phone:323-222-4591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-04
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89930106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist