Healthcare Provider Details

I. General information

NPI: 1396636130
Provider Name (Legal Business Name): JANESA SMITH
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 S QUINTANA DR
ANAHEIM CA
92807-4029
US

IV. Provider business mailing address

10106 MALLISON AVE
SOUTH GATE CA
90280-6142
US

V. Phone/Fax

Practice location:
  • Phone: 510-317-1444
  • Fax:
Mailing address:
  • Phone: 213-925-8722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: