Healthcare Provider Details

I. General information

NPI: 1487215372
Provider Name (Legal Business Name): DR. JESSICA GONZALEZ HAUGEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2019
Last Update Date: 10/28/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E CESAR E CHAVEZ AVE STE 230
LOS ANGELES CA
90033-2496
US

IV. Provider business mailing address

1720 E CESAR E CHAVEZ AVE
LOS ANGELES CA
90033-2414
US

V. Phone/Fax

Practice location:
  • Phone: 323-226-5789
  • Fax:
Mailing address:
  • Phone: 323-260-5789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1268
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: