MEDICARE: JENNIFER AHDOUT MD, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1366305914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JENNIFER AHDOUT MD, INC.

Provider Business Mailing Address
First Line	:	PO BOX 67779
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90067-0779
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1057 SELBY AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-3105
Country	:	US
Telephone Number	:	310-995-1557
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JENNIFER N AHDOUT
Credential	:
Telephone Number	:	310-995-1557

Provider Enumeration Date	:	12/09/2025
Last Update Date	:	12/09/2025

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