Healthcare Provider Details

I. General information

NPI: 1215603329
Provider Name (Legal Business Name): JENNIFER MARY BYRD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2021
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date: 09/21/2023
Reactivation Date: 09/26/2023

III. Provider practice location address

6957 N FIGUEROA ST
LOS ANGELES CA
90042-1245
US

IV. Provider business mailing address

PO BOX 90122
LONG BEACH CA
90809-0122
US

V. Phone/Fax

Practice location:
  • Phone: 323-443-3175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: