Provider Demographics
NPI:1851695258
Name:OLLESTAD, JENNIFER HEIDI
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HEIDI
Last Name:OLLESTAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 PIER AVENUE
Mailing Address - Street 2:#104
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405
Mailing Address - Country:US
Mailing Address - Phone:310-859-4611
Mailing Address - Fax:310-450-3318
Practice Address - Street 1:185 PIER AVENUE
Practice Address - Street 2:#104
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405
Practice Address - Country:US
Practice Address - Phone:310-859-4611
Practice Address - Fax:310-450-3318
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-29
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC42053106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist