=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215744164
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSE MEDEL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2024
-----------------------------------------------------
Last Update Date | 05/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 655 MAPLE AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90014-2211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-848-9194
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2381 YOSEMITE DR
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90041-2611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-713-8781
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 373H00000X
-----------------------------------------------------
Taxonomy Name | Day Training/Habilitation Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------