Healthcare Provider Details

I. General information

NPI: 1437661279
Provider Name (Legal Business Name): JESSICA SARAH VIOLETTE KIANMAHD MS, LCGC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 11/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PLAZA SUITE 265
LOS ANGELES CA
90095-0001
US

IV. Provider business mailing address

10833 LE CONTE AVE # 12-334
LOS ANGELES CA
90095-3075
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-6581
  • Fax: 310-206-8616
Mailing address:
  • Phone: 310-206-6581
  • Fax: 310-206-8616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberGC000907
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: