Healthcare Provider Details

I. General information

NPI: 1720851181
Provider Name (Legal Business Name): UNITED STATES VETERANS INITIATIVE - WEST LA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11401 VANDERGRIFT AVE
LOS ANGELES CA
90025-7127
US

IV. Provider business mailing address

800 W 6TH ST STE 1505
LOS ANGELES CA
90017-2742
US

V. Phone/Fax

Practice location:
  • Phone: 213-760-4630
  • Fax:
Mailing address:
  • Phone: 213-760-4630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: LISA R JACKSON-ZENO
Title or Position: MEDICAL BILLING PROJECT COORDINATOR
Credential:
Phone: 310-686-6092