Healthcare Provider Details

I. General information

NPI: 1164041877
Provider Name (Legal Business Name): JASMINE PENATE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2032 MARENGO ST
LOS ANGELES CA
90033-1319
US

IV. Provider business mailing address

2032 MARENGO ST
LOS ANGELES CA
90033-1319
US

V. Phone/Fax

Practice location:
  • Phone: 323-987-1034
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: