Provider Demographics
NPI:1427435841
Name:RELLOSA, JERTY A
Entity type:Individual
Prefix:
First Name:JERTY
Middle Name:A
Last Name:RELLOSA
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JERTY
Other - Middle Name:ANN
Other - Last Name:RELLOSA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:6931 VAN NUYS BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3980
Mailing Address - Country:US
Mailing Address - Phone:818-376-0134
Mailing Address - Fax:
Practice Address - Street 1:6931 VAN NUYS BLVD STE 102
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3980
Practice Address - Country:US
Practice Address - Phone:818-376-0134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA129716106H00000X
CA125729106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist