Healthcare Provider Details

I. General information

NPI: 1760135701
Provider Name (Legal Business Name): JESSE KHEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 09/10/2023
Certification Date: 09/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10618 KATELLA AVE
ANAHEIM CA
92804-6607
US

IV. Provider business mailing address

1731 E 120TH ST
LOS ANGELES CA
90059
US

V. Phone/Fax

Practice location:
  • Phone: 625-067-3115
  • Fax:
Mailing address:
  • Phone: 323-563-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: