Healthcare Provider Details

I. General information

NPI: 1699277293
Provider Name (Legal Business Name): DR. JACKLYN IBRAHIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 08/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8405 BEVERLY BLVD
LOS ANGELES CA
90048-3401
US

IV. Provider business mailing address

11350 CULVER BLVD
LOS ANGELES CA
90066-6088
US

V. Phone/Fax

Practice location:
  • Phone: 323-653-1990
  • Fax:
Mailing address:
  • Phone:
  • 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 Code122300000X
TaxonomyDentist
License Number104338
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: