Provider Demographics
NPI:1508519273
Name:NYSTROM, JENNIE (AMFT)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 N POINSETTIA PL APT 3
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-4318
Mailing Address - Country:US
Mailing Address - Phone:323-366-0081
Mailing Address - Fax:
Practice Address - Street 1:1355 N POINSETTIA PL APT 3
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90046-4318
Practice Address - Country:US
Practice Address - Phone:323-366-0081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT117665106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist