Healthcare Provider Details

I. General information

NPI: 1639782501
Provider Name (Legal Business Name): JACQUELINE OVSEPYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 W 58TH ST FL 2
LOS ANGELES CA
90037-3632
US

IV. Provider business mailing address

808 W 58TH ST FL 2
LOS ANGELES CA
90037-3632
US

V. Phone/Fax

Practice location:
  • Phone: 323-541-1600
  • Fax:
Mailing address:
  • Phone: 323-541-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number833253
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95016443
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: