Healthcare Provider Details

I. General information

NPI: 1770261521
Provider Name (Legal Business Name): JENNIFER DAVENPORT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6957 N FIGUEROA ST
LOS ANGELES CA
90042-1245
US

IV. Provider business mailing address

24255 PACIFIC COAST HWY DEPT 5000
MALIBU CA
90263-5000
US

V. Phone/Fax

Practice location:
  • Phone: 323-443-3175
  • Fax:
Mailing address:
  • Phone: 310-506-4608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number119611
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: