Healthcare Provider Details

I. General information

NPI: 1578238440
Provider Name (Legal Business Name): JESSICA MARIE MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2021
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 S KINNELOA AVE # 100
PASADENA CA
91107-3853
US

IV. Provider business mailing address

36 S KINNELOA AVE # 100
PASADENA CA
91107-3853
US

V. Phone/Fax

Practice location:
  • Phone: 626-844-3033
  • Fax: 626-609-2909
Mailing address:
  • Phone: 626-844-3033
  • Fax: 626-609-2909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: