Provider Demographics
NPI:1700235488
Name:BURKE, JAY EVAN (LMFT)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:EVAN
Last Name:BURKE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 N SEPULVEDA BLVD # 101
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5111
Mailing Address - Country:US
Mailing Address - Phone:213-293-6642
Mailing Address - Fax:
Practice Address - Street 1:633 W 5TH ST
Practice Address - Street 2:SUITE 26067
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90071-2005
Practice Address - Country:US
Practice Address - Phone:213-293-6642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91133106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist