Healthcare Provider Details

I. General information

NPI: 1750930129
Provider Name (Legal Business Name): JESSICA LA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2019
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9080 COLIMA RD
WHITTIER CA
90605-1600
US

IV. Provider business mailing address

202 S DEL MAR AVE APT B
SAN GABRIEL CA
91776-1348
US

V. Phone/Fax

Practice location:
  • Phone: 562-945-3561
  • Fax:
Mailing address:
  • Phone: 626-283-7318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: