Provider Demographics
NPI:1487847588
Name:CONNELLA, JACK (LMFT)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:CONNELLA
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4744 TELEPHONE RD # 3-182
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-5244
Mailing Address - Country:US
Mailing Address - Phone:310-452-3000
Mailing Address - Fax:
Practice Address - Street 1:4744 TELEPHONE RD # 3-182
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-5244
Practice Address - Country:US
Practice Address - Phone:310-452-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC21290106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist