Provider Demographics
NPI:1477887438
Name:RAY, JENNIFER LYNN (MA, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:RAY
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5535 BALBOA BLVD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1516
Mailing Address - Country:US
Mailing Address - Phone:818-497-7168
Mailing Address - Fax:
Practice Address - Street 1:5535 BALBOA BLVD
Practice Address - Street 2:SUITE 211
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1516
Practice Address - Country:US
Practice Address - Phone:818-497-7168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CALMFT86425106H00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA196856000Medicaid
CACMM70956FMedicaid