Healthcare Provider Details

I. General information

NPI: 1669245247
Provider Name (Legal Business Name): JESSICA SONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3727 W 6TH ST STE 200
LOS ANGELES CA
90020-5108
US

IV. Provider business mailing address

1745 HOLLY DR APT 106
GLENDALE CA
91206-4142
US

V. Phone/Fax

Practice location:
  • Phone: 213-235-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95024014
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: