=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770037715
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER R KNUTSON NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2016
-----------------------------------------------------
Last Update Date | 01/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2409 S. VERMONT AVE.
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-730-1663
-----------------------------------------------------
Fax | 323-730-9961
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 530 E WASHINGTON BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90015-3723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-730-1663
-----------------------------------------------------
Fax | 323-730-9961
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 95004553
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------