Provider Demographics
NPI:1750312211
Name:OWEN, GERALD JAY (MFT)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:JAY
Last Name:OWEN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 ARIZONA AVE # 1
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-1807
Mailing Address - Country:US
Mailing Address - Phone:310-395-9631
Mailing Address - Fax:310-458-3390
Practice Address - Street 1:911 ARIZONA AVE # 1
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1807
Practice Address - Country:US
Practice Address - Phone:310-395-9631
Practice Address - Fax:310-458-3390
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT20280106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist