Healthcare Provider Details

I. General information

NPI: 1558751859
Provider Name (Legal Business Name): JENNIE WYATT-COSTE 071607
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11643 GLENOAKS BLVD
PACOIMA CA
91331-1050
US

IV. Provider business mailing address

4760 SEPULVEDA BLVD
CULVER CITY CA
90230-4820
US

V. Phone/Fax

Practice location:
  • Phone: 818-897-2609
  • Fax: 818-890-7159
Mailing address:
  • Phone: 310-390-6612
  • Fax: 818-890-7159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number071607
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: