Healthcare Provider Details

I. General information

NPI: 1568060184
Provider Name (Legal Business Name): SIMONE A CATO-JACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12917 CERISE AVE
HAWTHORNE CA
90250-5520
US

IV. Provider business mailing address

12917 CERISE AVE
HAWTHORNE CA
90250-5520
US

V. Phone/Fax

Practice location:
  • Phone: 310-675-4431
  • Fax:
Mailing address:
  • Phone: 310-675-4431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number00965263
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: