Healthcare Provider Details

I. General information

NPI: 1053979880
Provider Name (Legal Business Name): JARRADE VICTOR DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 07/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 S VERMONT AVE
LOS ANGELES CA
90037-3527
US

IV. Provider business mailing address

8848 LINDELL AVE APT 7
DOWNEY CA
90240-2366
US

V. Phone/Fax

Practice location:
  • Phone: 323-751-3026
  • Fax:
Mailing address:
  • Phone: 530-632-4319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number89492
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: