Provider Demographics
NPI:1982155198
Name:GOLDMAN, JAKE EDWARD (LMFT)
Entity Type:Individual
Prefix:MR
First Name:JAKE
Middle Name:EDWARD
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 630
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4743
Mailing Address - Country:US
Mailing Address - Phone:213-915-4064
Mailing Address - Fax:
Practice Address - Street 1:2730 WILSHIRE BLVD
Practice Address - Street 2:SUITE 630
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4743
Practice Address - Country:US
Practice Address - Phone:213-915-4064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-23
Last Update Date:2016-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51273106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist