Healthcare Provider Details

I. General information

NPI: 1689375222
Provider Name (Legal Business Name): JESSICA BEATRICE DAVALOS LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 S ANITA DR STE 102-104
ORANGE CA
92868-3355
US

IV. Provider business mailing address

9808 VENICE BLVD STE 505
CULVER CITY CA
90232-6818
US

V. Phone/Fax

Practice location:
  • Phone: 310-945-3350
  • Fax:
Mailing address:
  • Phone: 310-945-3350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number756871
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: