Provider Demographics
NPI:1548565542
Name:BERNAL, JESSE SAMSON-JACOB (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:SAMSON-JACOB
Last Name:BERNAL
Suffix:
Gender:M
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:PO BOX 2212
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91102-2212
Mailing Address - Country:US
Mailing Address - Phone:323-326-8291
Mailing Address - Fax:
Practice Address - Street 1:1712 CORSON ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-1606
Practice Address - Country:US
Practice Address - Phone:323-326-8291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84944106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist