Provider Demographics
NPI:1679849129
Name:NAWAZ, JENNIFER RIZK
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RIZK
Last Name:NAWAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:RIZK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:245 E OLIVE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-1214
Mailing Address - Country:US
Mailing Address - Phone:626-283-5464
Mailing Address - Fax:
Practice Address - Street 1:43520 DIVISION ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-4089
Practice Address - Country:US
Practice Address - Phone:661-226-4783
Practice Address - Fax:661-226-1210
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA92295106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL