Provider Demographics
NPI:1942405402
Name:GORMAN, JAMIE RUNDBERG (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:RUNDBERG
Last Name:GORMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:JAMIE
Other - Middle Name:SAMANTHA
Other - Last Name:RUNDBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:183 W MARIPOSA ST
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-4761
Mailing Address - Country:US
Mailing Address - Phone:626-798-8890
Mailing Address - Fax:
Practice Address - Street 1:595 E COLORADO BLVD STE 423
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2018
Practice Address - Country:US
Practice Address - Phone:626-585-2271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS217791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical