Provider Demographics
NPI:1699025031
Name:PODELL, JENNIFER LYNN (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:PODELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 WESTWOOD PLZ
Mailing Address - Street 2:SUITE 48-256 A
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-8353
Mailing Address - Country:US
Mailing Address - Phone:310-825-8622
Mailing Address - Fax:
Practice Address - Street 1:760 WESTWOOD PLZ
Practice Address - Street 2:SUITE 48-256 A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-8353
Practice Address - Country:US
Practice Address - Phone:310-825-8622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25095103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1699025031Medicaid
CA1699025031Medicaid