Provider Demographics
NPI:1427353374
Name:BOEHMKE, JENNIFER (MFT INTERN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BOEHMKE
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8040 W MANCHESTER AVE, APT 209
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-7102
Mailing Address - Country:US
Mailing Address - Phone:661-940-4055
Mailing Address - Fax:
Practice Address - Street 1:5300 W AVENUE I
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-8312
Practice Address - Country:US
Practice Address - Phone:661-940-4055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-24
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57069106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist