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General NPI Number Information
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NPI Number | 1053699850
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Entity Type | Individual
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Provider Name | MRS. JACQUENE J RICHARDSON
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Gender | Female
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Dates
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Enumeration Date | 07/27/2011
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Last Update Date | 08/01/2011
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Provider Practice Location Address
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Address Line | 3875 S WESTERN AVE
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City | LOS ANGELES
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State | CA
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Zip | 90062-1105
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Country | US
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Telephone | 323-290-4373
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Fax |
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Provider Business Mailing Address
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Address Line | 498 W. 59TH STREET
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City | SAN BERNARDINO
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State | CA
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Zip | 92407
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Country | US
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Telephone | 323-290-4373
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 167G00000X
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Taxonomy Name | Licensed Psychiatric Technician
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License Number | PT36012
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License Number State | CA
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