Provider Demographics
NPI:1669099289
Name:PTAH, JAKUTA M
Entity type:Individual
Prefix:
First Name:JAKUTA
Middle Name:M
Last Name:PTAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8605 SANTA MONICA BLVD
Mailing Address - Street 2:PMB 922998
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4109
Mailing Address - Country:US
Mailing Address - Phone:818-569-9362
Mailing Address - Fax:
Practice Address - Street 1:8605 SANTA MONICA BLVD
Practice Address - Street 2:PMB 922998
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-4109
Practice Address - Country:US
Practice Address - Phone:818-892-3423
Practice Address - Fax:818-893-4509
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA144691106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL