Provider Demographics
NPI:1811920325
Name:JURKOWITZ, SUSAN WEISZ (PHD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:WEISZ
Last Name:JURKOWITZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10700 SANTA MONICA BLVD
Mailing Address - Street 2:STE #315
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-4702
Mailing Address - Country:US
Mailing Address - Phone:310-557-0852
Mailing Address - Fax:310-301-8751
Practice Address - Street 1:10700 SANTA MONICA BLVD
Practice Address - Street 2:STE #315
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-4702
Practice Address - Country:US
Practice Address - Phone:310-557-0852
Practice Address - Fax:310-301-8751
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15908103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY159080Medicaid
CAPSY159080Medicaid
CABC369ZMedicare PIN