Healthcare Provider Details

I. General information

NPI: 1912444688
Provider Name (Legal Business Name): JENNIE LE RUIZ NP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2017
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12001 NIETA DR
GARDEN GROVE CA
92840-3523
US

IV. Provider business mailing address

12522 LAMBERT RD
WHITTIER CA
90606-2758
US

V. Phone/Fax

Practice location:
  • Phone: 714-702-0090
  • Fax:
Mailing address:
  • Phone: 562-967-2273
  • Fax: 562-967-2911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95003804
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95003804
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95003804
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: