Provider Demographics
NPI:1891950820
Name:SO, JENNIFER CHUA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:CHUA
Last Name:SO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11835 W OLYMPIC BLVD STE 1265E
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-5814
Mailing Address - Country:US
Mailing Address - Phone:310-273-4843
Mailing Address - Fax:310-273-5056
Practice Address - Street 1:11835 W OLYMPIC BLVD STE 1265E
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064
Practice Address - Country:US
Practice Address - Phone:310-273-4843
Practice Address - Fax:310-273-5056
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-18
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26610103TC0700X
225400000X, 225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner