Basic Information
| Provider Information | |||||||||
| NPI: | 1609199736 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOVIS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MAELISA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 N ALTADENA DR | ||||||||
| Address2: | SUITE 1B | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911073386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267922812 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 40 N ALTADENA DR | ||||||||
| Address2: | SUITE 1B | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911073386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267922812 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2010 | ||||||||
| LastUpdateDate: | 01/25/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF87068 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | ICAN900 | 01 | CA | LA COUNTY DMH | OTHER |