Healthcare Provider Details

I. General information

NPI: 1023142155
Provider Name (Legal Business Name): MS. JENNIFER P MIXON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 INDUSTRY WAY
LYNWOOD CA
90262-4000
US

IV. Provider business mailing address

2640 INDUSTRY WAY
LYNWOOD CA
90262-4000
US

V. Phone/Fax

Practice location:
  • Phone: 310-639-5983
  • Fax: 310-639-5870
Mailing address:
  • Phone: 310-639-5983
  • Fax: 310-639-5870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: