Provider Demographics
NPI:1891043865
Name:METELLUS, JENNA I (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNA
Middle Name:I
Last Name:METELLUS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MS
Other - First Name:JENNA
Other - Middle Name:I
Other - Last Name:WASHINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 57064
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91413-2064
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6320 CANOGA AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-2526
Practice Address - Country:US
Practice Address - Phone:818-227-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-24
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
225C00000X, 390200000X
CA30486103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program