Healthcare Provider Details

I. General information

NPI: 1710690748
Provider Name (Legal Business Name): KASANDRA JASMINE IBARRA CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2023
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12021 WILMINGTON AVE BLDG. 18 SUITE 300
LOS ANGELES CA
90059
US

IV. Provider business mailing address

12021 WILMINGTON AVE BLDG. 18 SUITE 300
LOS ANGELES CA
90059
US

V. Phone/Fax

Practice location:
  • Phone: 424-454-6041
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number18041
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: