Healthcare Provider Details

I. General information

NPI: 1275758237
Provider Name (Legal Business Name): JENNIFER ELLICE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9333 IMPERIAL HWY
DOWNEY CA
90242-2812
US

IV. Provider business mailing address

1460 7TH ST STE 205
SANTA MONICA CA
90401-2631
US

V. Phone/Fax

Practice location:
  • Phone: 833-574-2273
  • Fax:
Mailing address:
  • Phone: 310-310-8031
  • Fax: 949-816-1967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberLP00217
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: