Provider Demographics
NPI:1427785203
Name:JEN, MELISSA (LCSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:JEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:OU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 31776
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:48 S SUNNYSIDE AVE
Practice Address - Street 2:
Practice Address - City:SIERRA MADRE
Practice Address - State:CA
Practice Address - Zip Code:91024-2316
Practice Address - Country:US
Practice Address - Phone:323-834-9889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW1041881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical