Healthcare Provider Details

I. General information

NPI: 1154939049
Provider Name (Legal Business Name): JIA HULBERT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2020
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 W 144TH ST APT 3
GARDENA CA
90247-2540
US

IV. Provider business mailing address

1207 W 144TH ST APT 3
GARDENA CA
90247-2540
US

V. Phone/Fax

Practice location:
  • Phone: 818-434-5735
  • Fax:
Mailing address:
  • Phone: 818-434-5735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberRDA94824
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: