Healthcare Provider Details

I. General information

NPI: 1144645649
Provider Name (Legal Business Name): JESSIE TIVAO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2014
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 W REDONDO BEACH BLVD FL 3
GARDENA CA
90247-4128
US

IV. Provider business mailing address

1045 W REDONDO BLVD 3RD FLOOR
GARDENA CA
90247
US

V. Phone/Fax

Practice location:
  • Phone: 310-970-5000
  • Fax: 323-967-0614
Mailing address:
  • Phone: 310-970-5000
  • Fax: 323-967-0614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW111726
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: