Provider Demographics
NPI:1487041562
Name:BORNA, JAZEH MAYA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JAZEH
Middle Name:MAYA
Last Name:BORNA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 AMHERST AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5805
Mailing Address - Country:US
Mailing Address - Phone:310-857-8497
Mailing Address - Fax:
Practice Address - Street 1:933 S SUNSET AVE STE 205
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3410
Practice Address - Country:US
Practice Address - Phone:310-857-8497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP12960235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist