Healthcare Provider Details

I. General information

NPI: 1306085196
Provider Name (Legal Business Name): MS. JENNIFER PETTY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 GRAND VIEW BLVD
LOS ANGELES CA
90066-5214
US

IV. Provider business mailing address

4160 GRAND VIEW BLVD
LOS ANGELES CA
90066-5214
US

V. Phone/Fax

Practice location:
  • Phone: 310-751-1101
  • Fax: 310-397-5827
Mailing address:
  • Phone: 310-751-1101
  • Fax: 310-397-5827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355A2700X
TaxonomyAudiology Assistant
License NumberSPA 953
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: