Provider Demographics
NPI:1174929244
Name:JAY, KATIE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:JAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 S FLOWER ST
Mailing Address - Street 2:602
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-1457
Mailing Address - Country:US
Mailing Address - Phone:510-599-8276
Mailing Address - Fax:
Practice Address - Street 1:3756 SANTA ROSALIA DR
Practice Address - Street 2:SUITE 628
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-3606
Practice Address - Country:US
Practice Address - Phone:323-293-8771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954505783OtherFEDERAL IDENTIFICATION NUMBER