Healthcare Provider Details

I. General information

NPI: 1023533049
Provider Name (Legal Business Name): JENNIFER L LLOYD RADT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2017
Last Update Date: 07/21/2022
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2515 E JEFFERSON ST
CARSON CA
90810-1519
US

IV. Provider business mailing address

13402 TRAUB AVE
LOS ANGELES CA
90059-3352
US

V. Phone/Fax

Practice location:
  • Phone: 310-830-7803
  • Fax: 310-830-6606
Mailing address:
  • Phone: 562-758-5392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1255590617
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: