Healthcare Provider Details

I. General information

NPI: 1457245706
Provider Name (Legal Business Name): JENNY VASQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9907 GRAPE ST
WATTS CA
90002-3112
US

IV. Provider business mailing address

9907 GRAPE ST
WATTS CA
90002-3112
US

V. Phone/Fax

Practice location:
  • Phone: 323-890-6415
  • Fax:
Mailing address:
  • Phone: 323-890-6415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number86095
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: