Provider Demographics
NPI:1588191811
Name:CHOMCHAVALIT, JENA RENAE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JENA
Middle Name:RENAE
Last Name:CHOMCHAVALIT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 E CENTURY BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90002-3050
Mailing Address - Country:US
Mailing Address - Phone:323-374-6848
Mailing Address - Fax:323-374-6691
Practice Address - Street 1:1220 E 4TH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-1831
Practice Address - Country:US
Practice Address - Phone:562-285-6774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-17
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 1041S0200X
CA1010331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool