Provider Demographics
NPI:1104684133
Name:WEITZ, JACQUELINE (MFCC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:WEITZ
Suffix:
Gender:F
Credentials:MFCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10122 EMPYREAN WAY APT 103
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-3804
Mailing Address - Country:US
Mailing Address - Phone:310-552-2336
Mailing Address - Fax:310-666-2995
Practice Address - Street 1:10122 EMPYREAN WAY APT 103
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-3804
Practice Address - Country:US
Practice Address - Phone:310-666-2995
Practice Address - Fax:310-666-2995
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFCC19233101YM0800X
CAMFT19233106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health