Provider Demographics
NPI:1619380409
Name:LI, JESSIE LIN (MFT-INTERN)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:LIN
Last Name:LI
Suffix:
Gender:F
Credentials:MFT-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 W OLYMPIC BLVD STE 550
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-1474
Mailing Address - Country:US
Mailing Address - Phone:213-553-1850
Mailing Address - Fax:213-383-3146
Practice Address - Street 1:605 W OLYMPIC BLVD STE 550
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-1474
Practice Address - Country:US
Practice Address - Phone:213-553-1850
Practice Address - Fax:213-383-3146
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF75642106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist