Healthcare Provider Details

I. General information

NPI: 1144572504
Provider Name (Legal Business Name): JEANNINE ENRIQUEZ PUGLIESE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 10/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 E FOOTHILL BLVD
PASADENA CA
91107-3464
US

IV. Provider business mailing address

2500 E FOOTHILL BLVD
PASADENA CA
91107-3464
US

V. Phone/Fax

Practice location:
  • Phone: 626-564-1613
  • Fax:
Mailing address:
  • Phone: 626-564-1613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number66485
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: