Healthcare Provider Details

I. General information

NPI: 1134636962
Provider Name (Legal Business Name): RAQUEL JUPITER NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2018
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 W 58TH ST
LOS ANGELES CA
90037
US

IV. Provider business mailing address

808 W 58TH ST
LOS ANGELES CA
90037-3632
US

V. Phone/Fax

Practice location:
  • Phone: 323-541-1411
  • Fax:
Mailing address:
  • Phone: 323-541-1411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95007958
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: