Provider Demographics
NPI:1861074502
Name:AXELROD, JENNA LEIGH (PHD)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:LEIGH
Last Name:AXELROD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17315 STUDEBAKER RD STE 105
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-2565
Mailing Address - Country:US
Mailing Address - Phone:562-999-4707
Mailing Address - Fax:877-741-9754
Practice Address - Street 1:17315 STUDEBAKER RD STE 105
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-2565
Practice Address - Country:US
Practice Address - Phone:562-999-4707
Practice Address - Fax:877-741-9754
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010512103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist