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General NPI Number Information
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NPI Number | 1174335632
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Entity Type | Individual
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Provider Name | JASON STEVE HENRIQUEZ
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Gender | Male
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Dates
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Enumeration Date | 01/22/2025
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Last Update Date | 01/22/2025
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Provider Practice Location Address
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Address Line | 578 WASHINGTON BLVD
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City | MARINA DEL REY
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State | CA
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Zip | 90292-5421
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Country | US
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Telephone | 424-272-5238
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Fax |
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Provider Business Mailing Address
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Address Line | 578 WASHINGTON BLVD
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City | MARINA DEL REY
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State | CA
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Zip | 90292-5421
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Country | US
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Telephone | 424-272-5238
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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 | 106E00000X
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Taxonomy Name | Assistant Behavior Analyst
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License Number |
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License Number State |
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