Provider Demographics
NPI:1285371229
Name:BERRY, JESSILINE (AMFT)
Entity type:Individual
Prefix:
First Name:JESSILINE
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 W PICO BLVD # 474
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-3451
Mailing Address - Country:US
Mailing Address - Phone:424-371-6081
Mailing Address - Fax:
Practice Address - Street 1:6363 WILSHIRE BLVD STE 520
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5727
Practice Address - Country:US
Practice Address - Phone:323-473-0181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT131923106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAMFT131923OtherBOARD OF BEHAVIORAL SCIENCES