Healthcare Provider Details

I. General information

NPI: 1629301213
Provider Name (Legal Business Name): MR. JEZREEL MARTIN SUPETRAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 HEYWOOD ST UNIT B
SIMI VALLEY CA
93065-6552
US

IV. Provider business mailing address

1000 S FREMONT AVE UNIT 34
ALHAMBRA CA
91803-8867
US

V. Phone/Fax

Practice location:
  • Phone: 805-694-8368
  • Fax:
Mailing address:
  • Phone: 626-997-4953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number61376
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: