MEDICARE: JESSICA DANOUSH

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	363A00000X	Physician Assistant	52235	CA

General Provider Information

NPI Number	:	1376933416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA DANOUSH

Provider Business Mailing Address
First Line	:	6223 LINDLEY AVE
Second Line	:
City	:	TARZANA
State	:	CA
Zip	:	91335-7118
Country	:	US
Telephone Number	:	818-792-8956
Fax Number	:

Provider Business Practice Location Address
First Line	:	5832 S VERMONT AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90044-3712
Country	:	US
Telephone Number	:	323-750-7354
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2015
Last Update Date	:	01/28/2015

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