Healthcare Provider Details

I. General information

NPI: 1396760252
Provider Name (Legal Business Name): JESSIE JEFFERY P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/21/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S LOCUST ST
INGLEWOOD CA
90301-1812
US

IV. Provider business mailing address

PO BOX 882454
LOS ANGELES CA
90009-3554
US

V. Phone/Fax

Practice location:
  • Phone: 310-412-3277
  • Fax: 310-412-3223
Mailing address:
  • Phone: 702-287-3813
  • Fax: 323-232-1924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19890
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: