Healthcare Provider Details

I. General information

NPI: 1669968574
Provider Name (Legal Business Name): JESSICA FLORES PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2018
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 E WASHINGTON BLVD
LOS ANGELES CA
90021-3068
US

IV. Provider business mailing address

2801 S SAN PEDRO ST
LOS ANGELES CA
90011-2023
US

V. Phone/Fax

Practice location:
  • Phone: 323-233-3100
  • Fax: 323-233-3124
Mailing address:
  • Phone: 323-233-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number55720
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: