Provider Demographics
NPI:1649671314
Name:THOMAS, JEAN
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:THOMAS
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 1:66 HURLBUT ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-4025
Mailing Address - Country:US
Mailing Address - Phone:626-441-4221
Mailing Address - Fax:626-441-6479
Practice Address - Street 1:95 N MARENGO AVE STE 200
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1746
Practice Address - Country:US
Practice Address - Phone:626-585-8075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225C00000X, 390200000X
CAPSY32701103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program