Provider Demographics
NPI:1639236391
Name:PEDERSON, JEAN ANITA (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:ANITA
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JEAN
Other - Middle Name:ANITA
Other - Last Name:HARDESTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:3621 EMANUEL DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1135
Mailing Address - Country:US
Mailing Address - Phone:818-248-8571
Mailing Address - Fax:818-541-9816
Practice Address - Street 1:6345 BALBOA BLVD
Practice Address - Street 2:SUITE 212
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1517
Practice Address - Country:US
Practice Address - Phone:818-881-1928
Practice Address - Fax:818-541-9816
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11446103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical