=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275242125
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAKE ANTHONY FABER FNP-BC, MSN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2022
-----------------------------------------------------
Last Update Date | 10/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3630 E IMPERIAL HWY
-----------------------------------------------------
City | LYNWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90262-2609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-900-8900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1155 1/2 N NEW HAMPSHIRE AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90029-1707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 95021708
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------