Provider Demographics
NPI:1528161122
Name:GIPSTEIN, JASON HAROLD (MFT)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:HAROLD
Last Name:GIPSTEIN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12304 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025
Mailing Address - Country:US
Mailing Address - Phone:310-207-1089
Mailing Address - Fax:
Practice Address - Street 1:12304 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025
Practice Address - Country:US
Practice Address - Phone:310-207-1089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC35614106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist