Provider Demographics
NPI:1750802658
Name:JAMIESON, KATHY MICHELE
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:MICHELE
Last Name:JAMIESON
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 1:19321 VICTORY BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-6302
Mailing Address - Country:US
Mailing Address - Phone:818-708-4500
Mailing Address - Fax:
Practice Address - Street 1:19321 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-6302
Practice Address - Country:US
Practice Address - Phone:818-708-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X, 172V00000X
CAASW1112641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker