Healthcare Provider Details

I. General information

NPI: 1245955707
Provider Name (Legal Business Name): JENNIFER MAI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2022
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11460 W WASHINGTON BLVD
LOS ANGELES CA
90066-6030
US

IV. Provider business mailing address

12101 DALE AVE SPC 92
STANTON CA
90680-6702
US

V. Phone/Fax

Practice location:
  • Phone: 310-337-7115
  • Fax:
Mailing address:
  • Phone: 408-680-6957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number302994
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: