Provider Demographics
NPI:1316080021
Name:TRAVIS, JEANNE ELLEN
Entity type:Individual
Prefix:MS
First Name:JEANNE
Middle Name:ELLEN
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E OLIVE AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-1849
Mailing Address - Country:US
Mailing Address - Phone:818-973-4899
Mailing Address - Fax:
Practice Address - Street 1:150 E OLIVE AVE STE 203
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-1849
Practice Address - Country:US
Practice Address - Phone:818-973-4899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45595106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist