Healthcare Provider Details

I. General information

NPI: 1669049334
Provider Name (Legal Business Name): JACQUELYN LOYA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4533 LAUREL CANYON BLVD
STUDIO CITY CA
91607-4122
US

IV. Provider business mailing address

4727 WILLIS AVE APT 203
SHERMAN OAKS CA
91403-2652
US

V. Phone/Fax

Practice location:
  • Phone: 818-980-7280
  • Fax:
Mailing address:
  • Phone: 559-679-3097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: