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General NPI Number Information
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NPI Number | 1669082434
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Entity Type | Individual
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Provider Name | JEROME PRUDENCIO JR.
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Gender | Male
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Dates
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Enumeration Date | 08/05/2020
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Last Update Date | 09/09/2025
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Provider Practice Location Address
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Address Line | 145 S FAIRFAX AVE FL 2
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City | LOS ANGELES
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State | CA
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Zip | 90036-2166
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Country | US
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Telephone | 310-502-8089
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Fax |
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Provider Business Mailing Address
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Address Line | 8816 LA RIVIERA DR UNIT D
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City | SACRAMENTO
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State | CA
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Zip | 95826-2075
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Country | US
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Telephone | 310-502-8089
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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 | 247200000X
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Taxonomy Name | Other Technician
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License Number |
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License Number State |
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