Healthcare Provider Details

I. General information

NPI: 1043912165
Provider Name (Legal Business Name): ALEC JESSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 MARENGO ST
LOS ANGELES CA
90033-1352
US

IV. Provider business mailing address

TCU BOX 297085
FORT WORTH TX
76129-0001
US

V. Phone/Fax

Practice location:
  • Phone: 323-409-1945
  • Fax:
Mailing address:
  • Phone: 817-257-6633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number15536
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: