Provider Demographics
NPI:1386393064
Name:EDISON, JA LYN NICOLE
Entity type:Individual
Prefix:MS
First Name:JA LYN
Middle Name:NICOLE
Last Name:EDISON
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:PO BOX 532
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90707-0532
Mailing Address - Country:US
Mailing Address - Phone:562-256-7717
Mailing Address - Fax:562-290-1230
Practice Address - Street 1:1360 W 6TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3514
Practice Address - Country:US
Practice Address - Phone:310-519-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA139779106H00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program