Provider Demographics
NPI:1417575499
Name:BENNETT, JENNA KARLSBERG
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:KARLSBERG
Last Name:BENNETT
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 1:221 N 3RD ST # 443
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-1202
Mailing Address - Country:US
Mailing Address - Phone:424-253-4656
Mailing Address - Fax:
Practice Address - Street 1:221 N 3RD ST # 443
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-1202
Practice Address - Country:US
Practice Address - Phone:424-253-4656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-07
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY34258103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist