Provider Demographics
NPI:1982369468
Name:TATUM, JERRON DEPAUL
Entity Type:Individual
Prefix:
First Name:JERRON
Middle Name:DEPAUL
Last Name:TATUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 W REGENT ST APT 305
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1044
Mailing Address - Country:US
Mailing Address - Phone:323-703-3278
Mailing Address - Fax:
Practice Address - Street 1:4325 GLENCOE AVE # 10082
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6444
Practice Address - Country:US
Practice Address - Phone:310-929-5519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110757106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist