Provider Demographics
NPI:1508286881
Name:MIRELES, JENNIFER ANN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:MIRELES
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 1:7768 VIA RONALDO
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-1432
Mailing Address - Country:US
Mailing Address - Phone:818-606-0811
Mailing Address - Fax:
Practice Address - Street 1:3787 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-4203
Practice Address - Country:US
Practice Address - Phone:323-373-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78748106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist