Provider Demographics
NPI:1134250988
Name:CONVER, JESSICA ANNE (MFT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:CONVER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:953 6TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-2722
Mailing Address - Country:US
Mailing Address - Phone:310-500-8545
Mailing Address - Fax:
Practice Address - Street 1:625 FAIR OAKS AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-2630
Practice Address - Country:US
Practice Address - Phone:626-395-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC42064101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health